Failure to Complete Admission MDS Assessment Within Required 14-Day Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete a required admission Minimum Data Set (MDS) assessment within the mandated timeframe for one resident. Record review on 3/19/26 at 11:20 A.M. showed that Resident C’s admission MDS assessment, dated with the resident’s admission date, was incomplete, despite the resident having been admitted on that same date. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s admission assessment should have been completed. The facility’s policy, “Guidelines for Assessments,” dated 5/29/24 and provided by RN 4 on 3/20/26 at 10:37 A.M., specifies that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission. The surveyors determined that this requirement was not met for Resident C, resulting in noncompliance with 410 IAC 16.2-3.1-31(d)(1). This citation relates to intakes 2803022 and 2799537.
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