Failure to Timely Submit MDS Assessments
Summary
The facility failed to complete and electronically submit encoded, accurate, and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for all 26 residents reviewed. Specifically, the MDS assessments for several residents were not submitted within 14 days after the assessment completion date, and others were not completed within 14 days following their Assessment Reference Date. This deficiency was identified during a standard survey conducted on February 13, 2025. The facility's policy, dated October 2019, requires that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, the facility did not adhere to these timeframes, resulting in significant delays. For instance, Resident #14's Quarterly MDS was due by December 31, 2024, but remained incomplete as of February 13, 2025, which was 44 days past the required completion date. Similarly, Resident #103's Annual MDS was due by December 30, 2024, and was 43 days overdue. Other residents also experienced delays in the submission of their MDS assessments. Interviews with facility staff revealed that the delays were attributed to staffing shortages, particularly in the social work department, and the need for additional training for a newly hired MDS Coordinator. The Registered Nurse responsible for MDS coordination acknowledged the late submissions and cited being busy and waiting on other departments to complete their sections as reasons for the delays. The Administrator and Regional Director of Clinical Reimbursement were aware of the overdue assessments and attributed the delays to staffing issues, indicating that they were doing what they could to manage the situation.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Resident #103/14/4/5/9/14/17/18/28/30/47/63/67/82/103/109/125/132 overdue MDS were completed on 3/3/25. Resident 6 and 78 were completed on 3/4/25. Resident 118 was completed on 3/5/25. Resident 110 was completed on 3/6/25. Resident #66 overdue MDS was completed on 2/25/25. Resident #122 was reviewed to ensure accuracy on 1/19/25. Resident #135 was reviewed to ensure accuracy on 2/28/25. All residents have the potential to be affected by this deficient practice. MDS(s) were reviewed for all residents related to compliance with MDS transmission timeframes. Areas identified will be assessed and corrected. The policy and procedure for MDS transmission was reviewed by the VP of Clinical Reimbursement and no changes were made. MDS Coordinator will be educated on RAI manual timeframes for transmission by the VP of Clinical Reimbursement. MDSC will review MDS assessment(s) for timely submission. Any identified will be submitted to QIES. MDS coordinator will review the MDS List “Completed,” “Export Ready” list within PCC twice a week for completed MDS(s) that are awaiting submission. Regional Director of Clinical Reimbursement will submit an audit related to MDS completion date and transmission on all residents including looking at the Assessment Reference Dates (ARD), completion date, submission due date for MDS weekly x4, biweekly x2, and monthly x3. All findings will be reported to the QAPI Committee for review and comment. Responsible party: DON
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s discharge MDS was not encoded and transmitted to the State within the required timeframe. The transfer form showed the resident was discharged, but the MDS record did not include a discharge assessment for that discharge, and the Regional MDS Coordinator said the facility MDS representative missed it and the facility follows RAI without a policy.
Failure to complete a reentry assessment for a resident who returned to the facility after a discharge with return anticipated. The record showed the resident came back to the facility, but there was no evidence that the required assessment was completed, and an E3 confirmed this during interview.
Failure to complete and submit a discharge MDS for a resident. Staff acknowledged the discharge assessment was never initiated or completed after the resident discharged, despite it being their responsibility and required for timely CMS submission. The resident had CKD stage 4, severe, and a BIMS score of 11 indicating moderate cognitive impairment.
Late Submission of Discharge MDS: The facility failed to timely transmit a resident’s Discharge Return Not Anticipated MDS to CMS after the resident was discharged home. The resident had multiple chronic conditions, including dementia, CKD, DM2, HTN, depression, psychosis, and metabolic encephalopathy, and was documented with severe cognitive impairment. The MDS was completed by the MDSC but not submitted until months later, despite the MDSC and DON acknowledging it should have been submitted within the required timeframe.
The facility failed to submit discharge MDS assessments for two residents who were discharged from the LTC facility. One resident had anemia, HTN, and atherosclerotic heart disease, and another had DM, cirrhosis of the liver, and HTN. The DON confirmed the assessments were not submitted to CMS, and the RAI manual requires discharge assessments to be completed and submitted within the required timeframes.
Failure to timely complete and transmit MDS assessments: completed assessments for two residents were still marked export ready and had not been sent to CMS, while another resident’s admission and Medicare 5-day MDSs remained in progress. The MDS Coordinator said the facility was behind, corporate staff were supposed to ensure exports, and the DON acknowledged the assessments should have been completed.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to encode and transmit the resident discharge assessment to the State within 7 days of assessment for one resident, Resident #9. Review of the EXCEL-SNF to Hospital Transfer form showed the resident was discharged on 7/15/2026, but review of the resident’s MDS assessments did not show a Discharge MDS Assessment for that discharge date. During interview, the Regional MDS Coordinator stated that the resident’s MDS was not updated because the facility MDS representative just missed it and that the facility does not have a policy, relying instead on the RAI.
Failure to Complete Reentry Assessment
Penalty
Summary
The facility failed to encode a subset of assessment items after a resident's reentry to the facility for 1 of 12 residents reviewed. Resident 34's discharge MDS dated May 27, 2024, indicated the resident was discharged with return anticipated. A late entry progress note dated June 7, 2026, documented that the resident returned to the facility on June 6, 2026. Review of the clinical record found no evidence that a reentry assessment was completed, and Employee E3 confirmed during interview on July 30, 2026, at 11:52 a.m. that the reentry assessment had not been completed.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete the discharge MDS for Resident #104 in accordance with CMS guidelines. Record review and staff interviews showed that the discharge assessment was never initiated or completed after the resident discharged, even though MDS Nurse #2 stated it was her responsibility to complete it and acknowledged it should have been initiated the day after discharge and submitted to CMS within the required timeframe. The facility policy stated it follows the RAI process per CMS protocol. Resident #104 was admitted with diagnoses including Chronic Kidney Disease, Stage 4, Severe, and an MDS review showed a BIMS score of 11, indicating moderate cognitive impairment.
Late Submission of Discharge MDS
Penalty
Summary
The facility failed to ensure the MDS for Resident 109 was transmitted to CMS within the required timeframe after the resident was discharged home on 2/9/2026. Resident 109 was admitted on 9/12/2025 with diagnoses including metabolic encephalopathy, type 2 diabetes, hypertension, dementia, chronic kidney disease, depression, and psychosis. The Discharge Return Not Anticipated MDS indicated the resident had severe cognitive impairment and was discharged home from the facility. During interview and record review, the MDS Coordinator stated the Discharge Return Not Anticipated MDS was completed on 2/13/2026 but was not submitted to CMS until 7/23/2026. The MDS Coordinator stated the assessment should have been submitted earlier, within 14 days after the discharge, and the DON also stated the submission was too late and should have been completed within 14 days of the completion date. The facility policy stated resident assessments are to be conducted and submitted in accordance with current federal and state submission timeframes, and the RAI Manual requires the discharge assessment to be completed within 14 days after discharge and submitted within 14 days after the MDS completion date.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit completed discharge MDS assessments within the required timeframe for two residents who were discharged from the facility. Resident #2 was admitted with diagnoses including anemia, hypertension, and atherosclerotic heart disease and was discharged without a discharge MDS assessment in the medical record. Resident #3 was admitted with diagnoses including diabetes mellitus, cirrhosis of the liver, and hypertension and was also discharged without a discharge MDS assessment in the medical record. During interview, the DON confirmed the facility had not submitted the discharge assessments for both residents to CMS. Review of the facility policy stated assessments were to be completed and submitted according to current federal and state timeframes, and the RAI manual stated discharge assessments must be completed within 14 days of discharge and submitted within 14 days of the MDS completion date.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to CMS within 14 days after completion of resident assessments for 3 of 3 sampled residents. R4’s MDS assessment for discharge/return anticipated dated 07/01/26 had been completed but was still listed as export ready and had not been exported to CMS. R1’s MDS assessment for discharge/return not anticipated dated 06/19/26 had also been completed but not exported and was listed as export ready. R5’s MDS assessments for Medicare/5-day and admission, both dated 07/06/26, were listed as in progress on 07/21/26. During interview, the MDS Coordinator stated the facility was behind, that corporate staff were supposed to ensure the assessments were exported, and that the coordinator was still training and had not been taught how to do everything. The MDS Coordinator acknowledged the assessments for R4, R5, and R1 were not complete and should have been. The DON also acknowledged the assessments should have been completed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.