Failure to Complete Quarterly MDS Assessment by Required Due Date
Penalty
Summary
The facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed by the required due date. Record review of the resident’s electronic health record showed that a quarterly MDS assessment was due to be completed by 02/16/26. However, the assessment was not completed by that date. During an interview on 03/09/26 at 12:35 pm, the Director of Nursing (DON) confirmed that the quarterly MDS assessment had been due on 02/16/26 and acknowledged that it was not completed as required. This failure to complete the quarterly MDS assessment as scheduled was identified for 1 of 3 residents reviewed for assessment accuracy and completion, and the report states that this deficient practice is likely to result in residents not receiving care and treatment that meet their current needs.
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