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F0638
D

Quarterly MDS Assessment Not Completed Within Required Timeframe

Durham, North Carolina Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required 92-day timeframe for one resident. Record review showed that after the resident's admission MDS assessment was completed, there was no quarterly MDS assessment available within the mandated period. Staff interviews confirmed that the resident had been discharged and readmitted multiple times within two months, but the quarterly MDS assessment, which should have been scheduled and completed within 92 days of the admission assessment, was missing. The MDS Coordinator and Administrator both acknowledged that the assessment was not completed or transmitted as required.

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