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F0640
B

Late Submission of Discharge MDS Assessments

Greensboro, North Carolina Survey Completed on 09-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit discharge Minimum Data Set (MDS) assessments within the required timeframe for two residents. For one resident, the discharge MDS assessment was completed and submitted more than a month after the resident was transferred to the hospital. For another resident, the discharge MDS was completed and submitted over a month after the resident was discharged to home. In both cases, the assessments were not encoded and transmitted to the State within the mandated 7-day period following the assessment reference date (ARD). Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator confirmed awareness of the backlog and stated that new MDS nurses had been hired due to the issue. The late completion and submission of the discharge MDS assessments were acknowledged by both the MDS staff and the Administrator during interviews.

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