Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) assessment for one resident within the required timeframe. The assessment, with a reference date of 4/7/2025, was completed and signed on 4/16/2025, but there was no documentation in the resident's electronic health record indicating that it had been transmitted to CMS as required. A review of the validation report confirmed that the assessment was not transmitted until 6/3/2025, well beyond the mandated submission period. During an interview, the MDS Coordinator acknowledged the oversight, stating that the assessment was missed and only submitted after the survey team requested it. Facility policy requires that all resident assessments be conducted and submitted in accordance with federal and state timeframes.