Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for two residents. According to the Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 days after the ARD. For one resident, the quarterly MDS assessment had an ARD of August 2, 2025, but was not completed until August 19, 2025. For another resident, the quarterly MDS assessment had an ARD of May 8, 2025, but was not completed until May 26, 2025. These findings were confirmed by the Registered Nurse Assessment Coordinator Consultant during an interview.