Failure to Complete Timely Annual MDS Assessment Due to Staffing Shortage
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment within the required twelve-month timeframe for one of five sampled residents. According to facility policy, the Assessment Coordinator is responsible for ensuring timely completion of resident assessments, including annual reviews. Record review showed that the annual MDS assessment for a resident, dated 04/15/25, was still in progress at the time of survey. Interviews with the administrator and regional director of operations revealed that the former MDS coordinator had quit suddenly, and there was no other trained staff available to perform the required assessments until about a week prior to the survey. As a result, the resident's annual assessment was not completed as required.