Delayed Submission of MDS Assessments
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required 14 days after completion for two residents. Resident #129's Quarterly MDS, with an assessment reference date of November 15, 2024, and a completion date of November 20, 2024, was not submitted until January 24, 2025. Similarly, Resident #225's Quarterly MDS, with an assessment reference date of November 18, 2024, and a completion date of November 27, 2024, was also submitted on January 24, 2025. During an interview, the MDS Coordinator acknowledged that the assessments were completed but not transmitted due to a change in status in the medical record to 'do not transmit' to the Centers for Medicare Services, though the reason for this change was unknown. The Director of Nursing was unaware of the delay and stated that the MDS Coordinator was responsible for submitting the assessments.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: The two residents who are affected with the deficient practice are scheduled for a new MDS schedule. Resident #129 next MDS schedule 2/14/25, and resident #225 2/17/25. The status of submission will be monitored with the use of the Monthly MDS schedule, starting with their new schedule. There was no negative outcome from the late submission. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the potential to be affected by this deficient practice. An audit was complete to review all MDS completed over the last 90 days and found that all were submitted timely. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? To ensure full compliance with the MDS schedules, an audit tool/checklist will be utilized to monitor full compliance to the timely CMS submission. "Facilities are required to electronically transmit MDS data to the CMS system for each resident in the facility." An audit tool was developed to ensure all submissions are submitted timely. A monthly MDS schedule that is derived from the PCC scheduler that the facility has been using was modified to include three columns: "PREVIOUS MDS/ARD/TRANSMISSION STATUS," "EXPORT READY," and "ACCEPTED." The MDS schedule of the next month is completed in the middle of the current month and modified ad lib. The RAUM Manager and/or designee checks her own assigned unit every week to ensure that MDSs are completed, locked with "EXPORT READY" status, and checks the said column in the MDS schedule. The Director of the Clinical Compliance and/or designee will transmit the "EXPORT READY" status MDSs to CMS. Upon completion of the transmission process in PCC, the RAUM Manager and/or designee checks the "ACCEPTED" column. A meeting with RAUM Managers and in-service regarding the transmission process will be conducted, and this audit will be done bi-weekly for two months, then bi-weekly for one month, and then monthly thereafter. This process will be monitored by the Director of MDS and/or designee. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? The MDS Schedule, the MDS report in PCC, and the IQIES report on MDS 3.0 Missing assessments will be utilized to complete the audit tool. The audit will be done by the Director of MDS or designee bi-weekly for one month, then monthly for three months. Results of the audits will be submitted to the Administrator, and results of the audits will be reported to the QAPI meeting monthly for three months for action as appropriate.
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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