Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the annual comprehensive MDS assessment had an ARD of 7/30/25 but was not signed as completed by the Registered Nurse (RN) MDS Coordinator until 9/3/25. Staff interviews confirmed that this assessment was completed late. For another resident, the annual MDS assessment had an ARD of 6/26/25 and was not completed until 8/15/25, with the Care Area Assessment (CAA) also completed on the same late date. Interviews with the MDS Coordinator and MDS Nurse #2 revealed that they were two months behind on completing MDS assessments when they began their positions at the facility and were still working to catch up. The facility's Administrator acknowledged awareness of the issue, noting that the new MDS nurses were behind on assessments upon starting. The Vice President of Operations confirmed that there was not a fully implemented Plan of Correction regarding the MDS assessments at the time of the survey.