Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure that the required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive assessment was completed 146 days late. The Director of Nursing (DON) confirmed that the last quarterly assessment for this resident was completed on January 23, 2025, and the annual comprehensive assessment, which was due on April 26, 2025, was not completed until June 18, 2025. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was not completed within the required 92-day interval. The last quarterly assessment was completed on February 16, 2025, and the subsequent assessment, due on May 19, 2025, was not completed until June 18, 2025, making it 122 days late. The DON acknowledged that the facility's policy and procedure, which requires timely completion of these assessments, was not followed.