Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. For one resident, the quarterly MDS assessment had an ARD of 7/10/25 but was not completed until 7/30/25. For another resident, the quarterly MDS assessment had an ARD of 7/23/25 and was completed on 8/20/25. Staff interviews revealed that the MDS Clinical Reimbursement Coordinator (CRC) was aware of the late assessments and attributed the delays to her responsibilities across multiple facilities, which prevented timely completion. The Director of Nursing (DON) and the Administrator both acknowledged awareness of the late MDS assessments, with the Administrator citing a vacant MDS CRC position as the reason for the delays.