Failure to Complete Timely Admission MDS Assessment Due to Staffing Shortages
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for one resident who was readmitted with a diagnosis of cerebral vascular accident (stroke). Record review showed that the admission MDS assessment, with an Assessment Reference Date (ARD) of 8/6/25, was still in process when reviewed on 8/20/25. Interviews with the MDS Coordinator and the Administrator confirmed that the assessment was not completed on time due to a high volume of pending MDS assessments and insufficient staffing, as the facility was in the process of hiring an additional full-time MDS nurse and had received only part-time assistance from corporate and a new part-time employee. This resulted in the resident not having a timely and complete assessment as required by regulations.