Failure to Complete Timely Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for four out of eight sampled residents within the required timeframes. Specifically, one resident with dementia had an annual Minimum Data Set (MDS) assessment that was incomplete past the deadline, as confirmed by the Director of Nursing Services (DNS). Another resident, readmitted with chronic kidney disease and a history of transient ischemic attack, did not have an admission MDS completed within the required 14 days. The DNS acknowledged responsibility for this delay. Additionally, a resident admitted after cardiovascular surgery had an admission MDS that was not completed by the deadline, with the responsible Registered Nurse Case Manager (RNCM) confirming the assessment was late and noting ongoing struggles with timely completion. Another resident with acute chronic diastolic heart failure had an admission MDS completed one day late, also acknowledged by the RNCM. These delays in completing required assessments placed residents at risk for unidentified care needs.