Failure to Complete Significant Change MDS Assessments Timely
Penalty
Summary
The facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the significant change in status MDS assessment had an ARD of 6/26/25 but was not signed as completed until 8/18/25. For another resident, who was admitted to hospice care, the significant change in status MDS assessment had an ARD of 8/7/25 and was not completed until 9/8/25. These delays were confirmed through staff interviews and record reviews. Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator acknowledged awareness of the issue and confirmed that the new MDS nurses were behind on assessments upon starting. The VP of Operations also confirmed that a Plan of Correction had not yet been fully implemented regarding the MDS assessment process.