F0638

D

Untimely Completion of Quarterly MDS Assessments

Hendersonville, North Carolina Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for three of thirty sampled residents. For one resident, the electronic medical record showed a quarterly MDS with an ARD of 09/29/25 that was not marked as completed until 10/22/25. For a second resident, the quarterly MDS had an ARD of 11/15/25 and was not completed until 12/04/25. For a third resident, the quarterly MDS had an ARD of 11/07/25 and was not completed until 12/02/25. These completion dates exceeded the regulatory timeframe tied to the ARD for quarterly assessments.

During a joint interview on 02/19/26, the MDS RN and Regional MDS Consultant confirmed that the quarterly MDS assessments for these three residents were not completed within the required regulatory timeframe. The MDS RN stated that the facility had experienced a high volume of new admissions and that staff had fallen behind on the number of MDS assessments needing completion. In a subsequent interview on 02/20/26 with the Administrator present, the Regional Director of Clinical Operations acknowledged that, despite good-faith efforts to address MDS issues, further improvement was still needed in completing assessments within regulatory timeframes.