Delayed Submission of Resident Assessments
Summary
The facility failed to ensure timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) system, as required by their policy. During a recertification survey, it was found that nine resident assessments were not submitted within the mandated 14 days of completion. The assessments for these residents had completion dates ranging from October 24, 2024, to November 1, 2024, but were not submitted until December 6, 2024. This delay was contrary to the facility's policy, which mandates timely submission of all Minimum Data Sets to CMS via the Internet Quality Improvement and Evaluation System. The issue arose due to an error in the submission process. The Assistant Director of Nursing, responsible for resident assessments, stated that a batch scheduled for submission on November 6, 2024, was accidentally missed. The Information Technology Support person confirmed that they had mistakenly submitted the same file twice, leading to one batch being overlooked. This error was not identified until the surveyor pointed it out during the survey. The Administrator acknowledged the mistake, noting it was the first occurrence of such an issue at the facility.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 were identified as being affected by the alleged gap in practice. The facility did not ensure that residents MDS were submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 MDS assessments were submitted immediately to Centers for Medicaid and Medicare Services system and accepted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. The MDS Coordinators reviewed all resident comprehensive, discharge and significant change assessment for the last 3 months for timely completion and submission. All MDS were completed, submitted and accepted. Responsible Party: MDS Coordinators 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? 1. The Policy and Procedure titled MDS 3.0 Submission was reviewed to assure compliance with F640 by the Administrator in conjunction with the Assistant Director of RA, Chief Information Officer and Director of QA/PI and revised accordingly. The changes in policy include “It is the Policy of Kings Harbor Multicare Center to ensure that all MDSs are submitted to CMS via IQIES within 14 days of completion” and “RA Coordinator will ensure receipt of the IQIES validation report from MIS on a daily basis.” Responsible Party: Administrator, Assistant Director of RA, Chief Information Officer, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all MDS Coordinators and Information Technology support personnel on the policy titled “MDS 3.0 Submission” revised 12/2024. Responsible Party: Inservice Coordinator/Designee 3. An Audit tool will be created to ensure that all batch MDS assessments are submitted within the 14 day requirement. Responsible Party: Director of QA/PI 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. All MDS batches will be audited to ensure submission within 14 days of completion, weekly x 4 weeks and then bi-weekly x 5 months. Responsible Party: Assistant Director of RA 2. The results of the MDS submission audit will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 3. Results of the MDS submission audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.
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.
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