Failure to Complete Required Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a timely comprehensive Minimum Data Set (MDS) assessment for one resident, resulting in noncompliance with required assessment timeframes. Facility policy titled "MDS 3.0 Completion" stated that an annual comprehensive assessment must be completed using an Assessment Reference Date (ARD) no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The resident’s electronic medical record showed an admission date of 02/18/2024 with diagnoses including bradycardia, epilepsy, and vascular dementia. Record review revealed that the last full comprehensive MDS assessment for this resident was completed on 01/24/2025, and no subsequent comprehensive assessment was completed within the required annual timeframe. During interviews, the MDS Coordinator II confirmed that a comprehensive assessment was not completed for this resident in February 2026, as required, and attributed the missed assessment to the previous MDS Coordinator’s failure to complete it. The Administrator stated that the MDS department should follow the Resident Assessment Instrument (RAI) Manual for guidance. The MDS Coordinator II further explained that the facility’s system for ensuring timely assessments involves completing an entry tracking assessment upon admission and then scheduling further MDS assessments based on the resident’s payor source, using the MDS Clinical List and the MDS tab to identify which assessment is due and when. Despite this system, the required annual comprehensive MDS assessment for this resident was not completed within the regulatory timeframe.
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