Failure to Submit MDS Assessments to CMS Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit required Minimum Data Set (MDS) resident assessments to CMS within the mandated timeframe. Facility policy dated 10/01/23 states that the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS’ Internet Quality Improvement Evaluation System in accordance with current federal and state guidelines, which require submission within 7 days of assessment. Record review showed that a discharge assessment for Resident #27, dated 11/07/25, and an annual assessment for Resident #13, dated 12/30/25, had not been submitted to CMS. During an interview on 02/10/26 at 1:55 p.m., the MDS coordinator confirmed that the MDS assessments for Resident #13 and Resident #27 were not submitted to CMS by the RN who reviewed and signed the assessments. The administrator reported that 74 residents resided in the facility at the time of the survey, and the two residents cited were part of the sample reviewed for MDS submission compliance.
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