Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete required admission Minimum Data Set (MDS) assessments within the mandated 14-day timeframe for two residents. Record review on 1/23/26 at 10:00 A.M. showed that Resident C’s admission MDS assessment, dated with an admission date documented in the record, was incomplete beyond the required completion window. Similarly, record review on 1/23/26 at 10:40 A.M. showed that Resident D’s admission MDS assessment, also dated with an admission date documented in the record, was incomplete and not finished within 14 calendar days of admission. During an interview on 1/23/26 at 11:55 A.M., the MDS nurse stated she had been busy working on a care plan project and had not completed all due MDS assessments. The DON provided a policy titled “Guidelines for Assessments,” dated 5/29/24, which states that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission, confirming that the incomplete assessments for these two residents were not done timely as required. No additional clinical history or specific medical conditions for the residents were documented in the report beyond their admission status and the timing and completeness of their MDS assessments.
