Failure to Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for all residents in Medicare/Medicaid-certified beds were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) from August 2024 onward. Review of the facility's MDS 3.0 NH Final Validation Report confirmed that the last successful transmission and validation occurred on 7/31/2024, with no subsequent submissions verified up to 8/11/2025. Interviews with the MDS coordinator revealed that she became aware of the transmission failure only after being notified by the California Department of Public Health, and that the facility's IT staff were working to resolve the issue and transmit the backlog of assessments. The MDS coordinator acknowledged that her responsibilities included ensuring timely and accurate MDS submissions and that the lack of transmission resulted in outdated assessments and care plans for residents. The Director of Nursing (DON) confirmed that the last MDS transmission occurred in 7/2024 and recognized that failure to submit MDS assessments in a timely manner leads to outdated care plans, which are essential for reflecting the current care provided to residents. Review of the facility's policy and procedure indicated that the MDS coordinator is responsible for transmitting assessments, correcting errors, and ensuring validation reports are received. The deficiency was identified through interviews and record review, with the absence of federally mandated resident assessment data affecting all residents in certified beds during the specified period.