Delayed Submission of MDS Assessment
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were transmitted to the Center for Medicare and Medicaid Services (CMS) within the required 14-day timeframe. This deficiency was identified during a recertification survey for a resident who had a significant change in condition. The resident, who had diagnoses including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Heart Failure, had a Significant Change MDS assessment completed on January 16, 2025. However, the assessment was not submitted to CMS until March 6, 2025, which was 35 days after completion. The delay in submission was attributed to the facility's reliance on a software system that tracks MDS assessment schedules. The system failed to generate a report listing the resident's assessment as due for transmission, leading to the oversight. Interviews with the MDS Director and Assistant Director revealed that they depended on the system to provide due dates for submissions, and the error was not identified until the survey. The facility's policy did not specify the timeframe for MDS completion and transmission, contributing to the oversight.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 I. The following actions were accomplished for the residents identified in the sample: The Minimum Data Set (MDS) for Resident #25 dated 1/10/25 and completed on 1/16/2025 was supposed to be submitted by 1/22/2025. The MDS director submitted this MDS on 3/6/2025, and it was accepted by the system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have MDS assessments completed have the potential to be affected by the same deficient practice. On (MONTH) 27, 2025, the MDS director generated a report of all MDS assessments that have not been submitted to ensure that there were no assessments that were late to be transmitted. There were no assessments (MDS) that were late to be transmitted. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The interdisciplinary team (IDT) reviewed the policy and procedure, on 03/24/2025, titled “MDS 3.0 Completion”. The IDT recommended adding to the responsibilities of the MDS director the following statement: Submit the MDS to both the CMS database as well as the state veterans home (SVH) databases within the timeframes established within the Resident Assessment Instrument guidelines as well the regulation under 483.20 (f)(1)-(4). In addition, the following statement was added: The MDS director, or designee will, generate the list for submission for all MDS assessments that are completed at a minimum, on a weekly basis. This list will be compared to the MDS calendar which contains all resident assessments that are scheduled, and is prepared by the MDS staff after reviewing the previously completed assessments. This will ensure that all MDS assessments which are due to be completed are submitted timely. The Facility Administrator, Director of Nursing and Medical Director reviewed the policy on 03/24/2025 and approved the addition. Beginning on 03/25/2025, the Director of Nursing (DON) re-educated all MDS staff members regarding the policy and procedure for MDS completion, including the change to the submission guidelines. This education will be completed by 03/28/2025. IV. The facility’s compliance will be monitored using the following Quality Assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that all completed MDS assessments are transmitted as per the RAI guidelines as well as the regulations under 483.20 (f) (1)-(4). Each week the MDS Director, or designee, will generate a list of all completed MDS assessments. They will compare the list of completed assessments to the MDS calendar to ensure that all scheduled assessments due for completion are completed and ready for transmission. Residents that have a completed MDS will be added to the audit tool to ensure compliance with transmittal. If MDS assessments are found to be past the required deadline for transmittal, the facility administrator, Director of Nursing, and Chief Financial Officer (CFO) will be notified immediately. Re-education will be provided to the MDS staff member, by the DON, if any MDS assessments are found to be past the required deadline for transmittal. The MDS director or designee will transmit all MDS assessments that are required to be transmitted. Following transmittal, the MDS director or designee will review the “MDS 3.0 NH Final Validation Report” to ensure that there were no assessments that contained errors or rejections. Any assessments that do contain errors or rejections will be reviewed and transmitted the same day as the original transmittal. These audits will be completed weekly for six (6) months, and then quarterly for two (2) consecutive quarters. The compliance standard will be set to 100%. At the end of the second quarterly audit, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits, and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: MDS Director
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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