Delayed MDS Submissions Due to Staffing and Process Gaps
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days after completion for several residents. The report highlights that multiple residents had their MDS assessments completed but not submitted in a timely manner, with delays ranging from 20 to 39 days past the completion date. This issue affected at least nine residents, including Residents #31, #79, and #88, among others. The delays in submission were attributed to staffing changes and gaps in the MDS Coordinator role. The MDS Nurse, who started at the facility in late January 2025, was still undergoing training and was responsible for managing both current and overdue assessments. The Director of Nursing (DON) was not initially aware of the need to sign and lock assessments completed before the new MDS Nurse's tenure, which contributed to the delays. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument Manual require timely submission of MDS assessments, which was not adhered to in these cases. Interviews with the MDS Nurse and the DON revealed a lack of clear communication and understanding of the submission process. The MDS Nurse was relying on electronic medical record software for scheduling, while the DON was new to the process and learning alongside the MDS Nurse. The Administrator expected timely transmission of MDS assessments within 14 days, as per the facility's policy and federal guidelines, but this expectation was not met due to the aforementioned issues.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
The facility failed to complete and transmit a required DRNA MDS for a resident who was discharged home with family and home health services. The census and progress note showed the resident’s status changed to STOP BILLING and the discharge occurred, but the MDS record showed no transmitted discharge assessment. The ADON/MDS coordinator stated the discharge MDS had been missed and that he sometimes delayed submission to ensure the resident was not readmitted, then may have forgotten to complete it.
A resident with dementia, cognitive impairment, and multiple pain-related diagnoses was transferred to the hospital after a cough and family request, but the facility did not properly update and retransmit the MDS discharge information when the anticipated return did not result in readmission. The MDS Nurse said the discharge MDS was completed, but the care plan remained open because the discharge was not manually changed from anticipated return to returned not anticipated, and the quarterly/annual MDS later showed as overdue.
Delayed MDS Transmission for Two Residents: The facility failed to timely complete and transmit discharge MDS assessments for two residents. One resident with DM, impaired cognition, and a planned discharge had a discharge MDS left in progress past the required timeframe, and another resident with chronic respiratory failure with hypoxia, severe cognitive impairment, and an unplanned hospital transfer also had a late discharge MDS. The MDSN stated both assessments should have been completed within 14 days, and the DON stated the MDSN should have followed MDS guidelines.
A resident with a fractured femur, HTN, and edema was discharged home, but the discharge resident assessment was not completed or transmitted as required. The DON said the MDS coordinator was responsible for MDS assessments, and the administrator later confirmed the discharge assessment had not been completed and that they were responsible for ensuring MDS completion.
Late Transmission of Discharge MDS Assessment: A resident with HTN and arthritis had a discharge MDS completed but not transmitted within the required timeframe. The MDS Coordinator said she was responsible for submitting MDSs and stated the delay was due to a software issue, while the Administrator said timely submission was expected under the facility policy and CMS guidelines.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Missed DRNA MDS for a Resident Discharged Home
Penalty
Summary
The facility failed to ensure a discharge return not anticipated (DRNA) MDS was completed and transmitted to CMS for one resident, R23, who was discharged home with family and was to receive home health services. R23’s census listing showed the resident’s status changed to STOP BILLING on 1/6/26, and a progress note the same day documented the discharge home. Review of the MDS listing dated 12/16/25 showed no record that the required DRNA MDS had been transmitted for the discharge. During interview, the ADON/MDS coordinator stated the discharge MDS had been missed and explained that he sometimes waited a few days to submit a discharge MDS to make sure the resident was not readmitted, and then may have forgotten to complete the assessment. The facility’s MDS 3.0 Assessment policy dated 8/20/24 stated that a discharge assessment should be completed within 14 days of discharge.
MDS Discharge Assessment Not Properly Updated After Hospital Transfer
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for one closed record, CR #154. CR #154 was admitted with diagnoses including right shoulder pain, unspecified fall, pain in unspecified joint, muscle wasting and atrophy of multiple sites, cognitive communication deficit, need for assistance with personal care, and dementia with no behavioral, psychotic, mood, or anxiety disturbance. A comprehensive MDS reflected a BIMS score of 08, indicating moderate impaired cognition. The discharge MDS reflected an unplanned discharge with anticipated return due to a short-term hospital transfer. CR #154 developed a cough on 01/20/2026, and the change-of-condition form documented that family wanted the resident sent to the hospital. The NP was notified and orders were given for a stat CXR, guaifenesin, and DuoNeb PRN. Progress notes show the family requested hospital transfer related to the cough, the DON was informed, and CR #154 was transported by EMS to the hospital on 01/23/2026. Additional notes reflected ongoing discussion with family about Medicare coverage and financial responsibility, and the facility admission, transfer, discharge log showed the resident discharged on 01/23/2026. On review of the record on 04/23/2026, CR #154's quarterly/annual MDS was 77 days overdue. During interview, the MDS Nurse stated she was responsible for transmitting MDS discharges and said the discharge MDS had been completed on 01/23/2026, but the care plan was not closed because the resident did not return within 30 days and the system did not generate the expected notification. RRN A stated that when a resident discharges with anticipated return and does not readmit, the facility must manually complete a discharge deletion so the care plan closes and no further MDS tasks trigger, and he stated the discharge was not manually changed from anticipated return to returned not anticipated. The facility policy stated that a significant correction assessment must be completed no later than the 14th calendar day after determination that a significant error occurred and that a Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay.
Delayed MDS Transmission for Two Residents
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted timely to CMS for two residents. For Resident 22, the record showed an original admission on 5/24/2023 and a later readmission, with diagnoses including DM. The MDS indicated the resident had moderately impaired cognition, required supervision or touching assistance with eating, and had a planned discharge. The census report showed the resident was discharged on 1/28/2026, and the physician order and nursing progress note both documented discharge to a board and care facility on that date. Resident 22’s MDS Summary showed the ARD for the discharge assessment was 1/28/2026 and that the MDS was to be completed by 2/11/2026, but the assessment was still in progress at the time of review. During interview, the MDSN stated there was no discharge MDS completed for Resident 22 when discharged and that the discharge assessment should have been completed within 14 days. The MDSN stated he was not sure why it was not completed and submitted, and noted that timely completion is important so CMS can know a resident’s functioning status and monitor for improvement or decline. The MDS record later showed the assessment was signed as completed on 4/24/2026. For Resident 166, the record showed an original admission on 12/02/2025 and a later readmission, with diagnoses including chronic respiratory failure with hypoxia. The MDS indicated the resident had severely impaired cognition, was dependent on staff for dressing and personal hygiene, and the assessment was for an unplanned discharge. The census report showed the resident was transferred to the hospital on 1/30/2026, and the MDS Summary showed the ARD for the discharge assessment was 1/30/2026 with a completion date of 2/17/2026. During interview, the MDSN stated the discharge assessment should have been completed within 14 days and that the completion date should have been 2/13/2026, but he was not sure why it was not completed timely. The DON stated the MDSN should have completed both residents’ MDS assessments according to MDS guidelines so there would be no delays in care and discharge plans would be implemented.
Incomplete Discharge Assessment and MDS Transmission
Penalty
Summary
The facility failed to ensure a resident discharge assessment was completed and transmitted to the State within 7 days of assessment for Resident #74. Resident #74’s electronic record showed diagnoses including fracture of the left femur, hypertension, and edema, and a Post-Discharge Plan of Care dated 02/28/26 showed the resident was discharged to home. However, there was no documentation that a discharge resident assessment was completed. During interview on 04/13/26, the DON stated the MDS coordinator was responsible for completing MDS assessments, and the administrator later reviewed the record and stated the discharge assessment had not been completed and should have been completed. The administrator also stated they were responsible for ensuring the MDS was completed and that they were the RN who signed off for completed MDS assessments.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident #10’s discharge MDS assessment was electronically completed and transmitted to the CMS system within 14 days after completion. Resident #10 was a male admitted to the facility with diagnoses including hypertension and arthritis, and his admission MDS showed a BIMS score of 14 with no cognitive impairment. The face sheet indicated that he was discharged on 11/01/2025, and record review on 04/15/2026 showed that no discharge MDS had been transmitted prior to survey intervention. During interview, the MDS Coordinator stated she was responsible for completing and submitting MDS assessments and acknowledged that Resident #10’s discharge assessment had been completed but not transmitted within 14 days of discharge. She said the corporate MDS coordinator monitors the assessments she completed and stated the assessment was not transmitted because of a software issue. The Administrator stated she expected the MDS Coordinator to follow the facility’s MDS Completion and Submission policy and said timely submission was important to ensure the facility was following CMS guidelines.
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