Failure to Complete Quarterly MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for one resident. According to the Resident Assessment Instrument (RAI) User's Manual, a quarterly MDS assessment must have an assessment reference date (ARD) no more than 92 days after the ARD of the most recent assessment, and must be completed within 14 days after the ARD. For one resident, the admission MDS assessment had an ARD of March 31, 2025, but there was no evidence that the subsequent quarterly MDS assessment was completed within the required 90-day period. This was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview, who acknowledged that the quarterly MDS assessment was not completed as required.