cms_WY: 21
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 21 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2017-10-04 | 278 | E | 1 | 1 | GX9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Resident Assessment Instrument User's Manual, and staff interview, the facility failed to ensure the MDS assessment was certified as complete in a timely manner for 9 of 18 sample residents (#9, #17, #23, #36, #47, #64, #65, #83, #90). The findings were: Review of timeliness criteria in Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14 (section 5.2), by the Centers of Medicare and Medicaid Services, showed the MDS completion date (item Z0500B) must be no later than the 14th calendar day of the resident's admission for an admission assessment and no later than the assessment reference date (ARD) plus 14 days for an annual assessment. For a significant change assessment, the completion date must be no later than 14 days after the determination that a significant change has occurred. The following concerns were identified: 1. Review of the admission MDS assessment, with an ARD of 5/23/17, revealed resident #65 was admitted on [DATE]. Further review of section V showed the RN certified the assessment as being complete on 6/8/17 (the 23rd day after admission). 2. Review of the annual MDS assessment for resident #83 revealed an ARD of 3/31/17. Review of section V showed the RN had not certified the assessment as being complete until 4/17/17 (17 days after the ARD). 3. Review of the annual MDS assessment for resident #64 revealed an ARD of 10/20/16. Review of section V showed the RN had not certified the assessment as being complete until 11/16/17 (28 days after the ARD). Review of the significant change MDS assessment with an ARD of 6/21/17 for the same resident showed it was not certified as complete until 7/11/17 (20 days after the ARD). 4. Review of the significant change MDS assessment for resident #23 showed an ARD of 5/16/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 6/8/17 (23 days after the ARD). 5. Review of the annual MDS assessment for resident #17 showed an ARD of 12/22/16. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (60 days). 6. Review of the significant change MDS assessment for resident #9 showed an ARD of 1/20/17 and a completion date of 2/23/17 (34 days after the ARD). Review of the significant change MDS assessment for resident #9 showed an ARD of 8/22/17 and a completion date of 9/18/17 (27 days after the ARD). 7. Review of the annual MDS assessment for resident #90 showed an ARD of 1/18/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/27/17 (40 days). 8. Review of the admission MDS assessment for resident #36 showed an ARD of 1/19/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (23 days). 9. Review of the admission MDS assessment for resident #47 showed an ARD of 1/20/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (22 days). 10. Interview on 10/4/17 at 9:55 AM with the MDS coordinator revealed she was aware of the 14 day completion deadline and verified the MDS assessments were not completed within the correct timeframe. | 2020-09-01 |