Missed Quarterly MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed for a resident as required. Record review showed that the resident was originally admitted in early 2021 and most recently readmitted in mid-2024. Examination of the resident's MDS 3.0 assessments revealed that a quarterly MDS was completed in January 2025 and an annual MDS in June 2025, but there was no evidence of any MDS assessments being completed between these dates. According to the MDS Coordinator, a quarterly assessment should have been completed around April 2025, but this was not done, and the coordinator was unable to provide a reason for the omission. The resident was not out of the facility during the time the assessment was due. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Health Services, and Executive Director, confirmed that the responsibility for completing MDS assessments rested with the MDS Coordinator, and that all expected the assessments to be completed on time. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual confirmed that quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment. The failure to complete the required quarterly MDS assessment resulted in a deficiency for the facility.