Failure to Complete MDS Entry Tracking Record for Readmitted Resident
Summary
The facility failed to complete the required Minimum Data Set (MDS) entry tracking record for a resident who was readmitted to the facility after being discharged to an acute care hospital with the expectation of return. The Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual mandates that an entry tracking record must be completed every time a resident is admitted or readmitted to a nursing home. This record must be completed within 7 days after the admission or reentry and submitted no later than the 14th calendar day after the entry. However, for this resident, no entry tracking record was found in their clinical record following their readmission. The resident in question was initially admitted to the facility with diagnoses including Striatonigral Degeneration and Adult Failure to Thrive. They were discharged to the hospital and subsequently readmitted to the facility three days later. Despite the requirement, the facility did not complete the entry tracking record upon the resident's return. During an interview, the MDS Coordinator acknowledged that the entry tracking record should have been completed but was not. The facility lacked a specific policy and procedure for the completion of MDS assessments and tracking, relying instead on the RAI manual as a guide.
Penalty
Resources
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The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
A resident’s quarterly MDS assessment was not electronically transmitted within the required 14-day timeframe. Review of the MDS log showed the quarterly assessment with a specific ARD remained in Draft status in the facility’s software and had not been encoded or transmitted. In an interview, the DON confirmed the assessment was due, acknowledged it was not transmitted, and stated that all MDS assessments are expected to be transmitted timely.
A resident’s Quarterly MDS assessment was not completed and transmitted within the required 14-day period following the ARD. Record review showed that the ARD was set, but the RN did not sign the assessment completion until several weeks later, and the MDS Coordinator confirmed during interview that the assessment was not completed and transmitted within the mandated timeframe.
Surveyors found that required MDS assessments were not electronically submitted to CMS within the required timeframe for two residents. Facility policy assigns responsibility to the assessment coordinator or designee to ensure timely submission of assessments in accordance with federal and state guidelines. Record review showed that one resident’s discharge assessment and another resident’s annual assessment had not been submitted, and the MDS coordinator confirmed that the RN who reviewed and signed these assessments did not complete the submission process.
A resident was discharged to the hospital, but the facility failed to complete and submit the required discharge MDS within the mandated 14-day timeframe. Review of the EHR showed the discharge MDS was not submitted and accepted until more than four months after discharge. In an interview, the MDSC confirmed the assessment was late and acknowledged it should have been submitted within the required period.
The facility failed to transmit required MDS assessments within regulatory timeframes for two residents. For one resident with type 2 DM and HTN, a quarterly MDS was completed but not transmitted as expected, which the DON attributed to a system glitch that prevented automatic submission. For another resident who had been discharged, a discharge MDS was completed but not transmitted or accepted by the CMS system, and the DON acknowledged that the MDS nurse should have monitored transmission reports and ensured submission within the required 14-day window.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Failure to Transmit Quarterly MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure timely electronic transmission of a federally mandated Minimum Data Set (MDS) quarterly assessment for one of three residents reviewed for MDS transmittal requirements. Record review showed that this resident’s MDS log listed a quarterly assessment with an Assessment Reference Date (ARD) of 02/16/26 that had not been transmitted. Further review of the quarterly assessment in the facility’s software revealed it remained in Draft status, indicating it was not completed, encoded, or transmitted. During an interview on 03/09/26 at 12:35 p.m., the DON confirmed that the quarterly MDS assessment was due on 02/16/26, acknowledged that it had not been transmitted electronically, and stated that all MDS assessments should be transmitted within the required 14-day timeframe, which did not occur in this case. This deficient practice was identified for 1 resident (R #1) out of 3 residents (R #1, #2, and #3) reviewed for compliance with MDS transmittal requirements, and the report notes that such a failure is likely to hinder the ability of regulatory bodies to oversee resident care and prevents the facility from accurately tracking clinical trends or declines in a resident’s condition over time.
Failure to Complete and Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for one of three residents reviewed. Record review showed that this resident’s Quarterly MDS had an ARD of 01/14/26, but the RN did not sign the assessment completion date until 02/10/26. During an interview on 02/16/26 at 4:50 PM, the MDS Coordinator confirmed that this MDS assessment was not completed and transmitted within the required 14-day timeframe. This failure involved only the timeliness of the MDS completion and transmission; no additional clinical details, medical history, or resident condition at the time of the deficiency were documented in the report.
Failure to Submit MDS Assessments to CMS Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit required Minimum Data Set (MDS) resident assessments to CMS within the mandated timeframe. Facility policy dated 10/01/23 states that the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS’ Internet Quality Improvement Evaluation System in accordance with current federal and state guidelines, which require submission within 7 days of assessment. Record review showed that a discharge assessment for Resident #27, dated 11/07/25, and an annual assessment for Resident #13, dated 12/30/25, had not been submitted to CMS. During an interview on 02/10/26 at 1:55 p.m., the MDS coordinator confirmed that the MDS assessments for Resident #13 and Resident #27 were not submitted to CMS by the RN who reviewed and signed the assessments. The administrator reported that 74 residents resided in the facility at the time of the survey, and the two residents cited were part of the sample reviewed for MDS submission compliance.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and submitted within the required 14 days for one resident. The resident was admitted to the facility and later discharged to the hospital, but review of the electronic health record showed that the discharge MDS was not submitted and accepted until 123 days after the resident’s discharge. During an interview, the MDS Coordinator acknowledged that the discharge MDS for this resident was late, confirmed it was not completed until the following year, and stated that it should have been submitted within 14 days of the resident’s discharge but was not. The report notes that if MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care.
Failure to Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for two residents. For Resident #1, who was admitted with diagnoses including type 2 diabetes and hypertension, a quarterly MDS with an Assessment Reference Date (ARD) of 11/14/25 was completed on 11/26/25 but had not been transmitted as of the time of review. The MDS coordinator was unavailable for interview, and the Director of Nursing (DON) verified that this quarterly MDS had not been transmitted, stating there was a system glitch and that it should have automatically transmitted when completed. The Administrator stated it was his expectation that all MDS assessments be transmitted on time. For Resident #30, the electronic medical record showed an admission and subsequent discharge on 9/18/25. A discharge MDS with an ARD of 9/18/25 was signed as completed by the facility’s MDS nurse on 10/3/25, but the record did not show that this discharge MDS had been transmitted to or accepted by the CMS system. During interviews, the DON and Administrator confirmed that the MDS nurse was unavailable and acknowledged that the 9/18/25 discharge MDS had not been transmitted. The DON further stated that the MDS nurse should have been monitoring a print-out that would indicate whether MDS assessments were successfully transmitted and accepted, and acknowledged that the discharge MDS should have been transmitted within 14 days of the ARD.
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