Failure to Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for two residents. For Resident #1, who was admitted with diagnoses including type 2 diabetes and hypertension, a quarterly MDS with an Assessment Reference Date (ARD) of 11/14/25 was completed on 11/26/25 but had not been transmitted as of the time of review. The MDS coordinator was unavailable for interview, and the Director of Nursing (DON) verified that this quarterly MDS had not been transmitted, stating there was a system glitch and that it should have automatically transmitted when completed. The Administrator stated it was his expectation that all MDS assessments be transmitted on time. For Resident #30, the electronic medical record showed an admission and subsequent discharge on 9/18/25. A discharge MDS with an ARD of 9/18/25 was signed as completed by the facility’s MDS nurse on 10/3/25, but the record did not show that this discharge MDS had been transmitted to or accepted by the CMS system. During interviews, the DON and Administrator confirmed that the MDS nurse was unavailable and acknowledged that the 9/18/25 discharge MDS had not been transmitted. The DON further stated that the MDS nurse should have been monitoring a print-out that would indicate whether MDS assessments were successfully transmitted and accepted, and acknowledged that the discharge MDS should have been transmitted within 14 days of the ARD.
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