Late Completion of Admission MDS Assessment
Penalty
No penalty information released
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 complete a comprehensive admission Minimum Data Set (MDS) assessment within the required 14-day timeframe for one resident. According to facility policy and the MDS User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission, except in certain readmission scenarios. Record review showed that a resident was admitted on 9/9/2025, but the admission MDS was not signed as completed until 10/11/2025, which was 13 days past the required deadline. This was confirmed by the Regional Director of Operations during an interview.