Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for eight residents. Record reviews and staff interviews confirmed that the MDS assessments for these residents were completed late, with some assessments being overdue by several weeks. In one case, an assessment had not yet been completed as of the date of the review, making it six days overdue. The MDS Coordinator and another MDS nurse confirmed during interviews that these assessments were not completed on time. The deficiency was identified through a combination of medical record reviews and staff interviews. The MDS Coordinator and MDS Nurse #2 reported that when they began their positions, they inherited a backlog of MDS assessments that were already two months behind schedule. Despite their ongoing efforts to catch up, several assessments continued to be completed outside the required timeframe. The Administrator and the company's VP of Operations were aware of the issue and acknowledged that the facility was behind on MDS assessment completion. Specific examples included assessments for multiple residents that were signed as completed well beyond the 14-day window after the ARD, and in one instance, an assessment was not completed at all by the time of the survey. The report documents that the facility did not have a fully implemented Plan of Correction regarding the timely completion of MDS assessments at the time of the survey.