Late Submission of Quarterly MDS Assessment
Penalty
Fine: $26,685
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The assessment, with an Assessment Reference Date (ARD) of 7/11/2025, was completed on 7/25/2025 but was not submitted and accepted until 8/19/2025, which was 11 days past the required submission date. During an interview, the staff member responsible for completing the MDS assessments acknowledged that some assessments were late due to being overburdened with responsibilities, including covering additional shifts on the floor. Review of the facility's policy confirmed the requirement to utilize the current version of the RAI (MDS 3.0) and follow the instructions in the RAI Manual.