Incomplete MDS Cognitive Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments, specifically in Section C: Cognitive Patterns, for four of twenty-one sampled residents. A facility document titled “MDS Completion and Submission Timeframes,” dated October 2023, stated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. However, record review showed that a quarterly assessment for Resident #57 dated 11/01/25, an admission assessment for Resident #87 dated 11/21/25, an annual assessment for Resident #44 dated 12/11/25, and a quarterly assessment for Resident #69 dated 12/12/25 all had Section C marked as “not assessed” and left incomplete. During interviews on 02/12/26, the MDS coordinator acknowledged in each case that Section C should have been assessed and answered, and the DON stated they could not explain why Section C was not completed and confirmed it should have been assessed and answered correctly. These findings occurred in a facility where the administrator identified that 74 residents resided, and the deficiency was identified through record review and staff interviews focused on MDS accuracy for sampled residents.
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