F0641

D

Failure to Complete Admission MDS Assessment Within Required Timeframe

Middletown, New York Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate and timely completion of a federally required admission Comprehensive Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and type 2 diabetes mellitus. Facility policy required a systematic MDS scheduling process, including establishment of an Assessment Reference Date (ARD) within the allowable window and maintenance of an MDS scheduling calendar and tracking log. Record review showed that a comprehensive MDS assessment was required within 14 days of admission, but the assessment associated with an ARD of 12/23/2025 was not completed by that timeframe and was already 10 days overdue at the time of the initial record review on 01/02/2026.

Interviews and further record review revealed that the MDS coordinator had the resident’s ARD tracking under a prior admission that ended in discharge in August 2025, and the comprehensive care plan from that prior admission had not been completed and closed by all disciplines. This prevented closure of the previous admission assessment cycle and left the prior ARD active, which interfered with the MDS process for the current admission. The MDS coordinator stated that the resident’s new admission had been treated as a readmission and the admission status was not verified, contributing to the failure to complete the new comprehensive assessment within the required 14-day timeframe. The administrator reported being unaware of any MDS or ARD tracking issues and had not been notified of delays. On revisit, the comprehensive assessment for the current admission remained incomplete, with required sections from other disciplines still outstanding and the ARD 35 days overdue.