F0636

D

Failure to Complete Annual MDS Assessments Within Required Timeframe

Burlington, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required annual Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. Record review showed that one resident, admitted on an unspecified date, had an annual MDS with an ARD of 2/6/26 that remained in progress and was not completed. Another resident, also admitted on an unspecified date, had an annual MDS with an ARD of 1/28/26 that likewise remained in progress and was not completed. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the assessments for these residents were incomplete, attributing this to transitioning from previous job duties. In a separate interview, the DON and the Administrator each acknowledged awareness that some MDS assessments were behind or past due, while stating their expectation that MDS assessments be completed timely to meet federal regulations.

These findings demonstrate that the facility did not assess residents completely in a timely manner upon admission and periodically at least every 12 months, as required, because the annual MDS assessments for the two residents were not completed within the regulatory timeframe following the ARD.