Delayed Submission of MDS Assessments
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required 14 days after completion for two residents. Resident #129's Quarterly MDS, with an assessment reference date of November 15, 2024, and a completion date of November 20, 2024, was not submitted until January 24, 2025. Similarly, Resident #225's Quarterly MDS, with an assessment reference date of November 18, 2024, and a completion date of November 27, 2024, was also submitted on January 24, 2025. During an interview, the MDS Coordinator acknowledged that the assessments were completed but not transmitted due to a change in status in the medical record to 'do not transmit' to the Centers for Medicare Services, though the reason for this change was unknown. The Director of Nursing was unaware of the delay and stated that the MDS Coordinator was responsible for submitting the assessments.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: The two residents who are affected with the deficient practice are scheduled for a new MDS schedule. Resident #129 next MDS schedule 2/14/25, and resident #225 2/17/25. The status of submission will be monitored with the use of the Monthly MDS schedule, starting with their new schedule. There was no negative outcome from the late submission. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the potential to be affected by this deficient practice. An audit was complete to review all MDS completed over the last 90 days and found that all were submitted timely. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? To ensure full compliance with the MDS schedules, an audit tool/checklist will be utilized to monitor full compliance to the timely CMS submission. "Facilities are required to electronically transmit MDS data to the CMS system for each resident in the facility." An audit tool was developed to ensure all submissions are submitted timely. A monthly MDS schedule that is derived from the PCC scheduler that the facility has been using was modified to include three columns: "PREVIOUS MDS/ARD/TRANSMISSION STATUS," "EXPORT READY," and "ACCEPTED." The MDS schedule of the next month is completed in the middle of the current month and modified ad lib. The RAUM Manager and/or designee checks her own assigned unit every week to ensure that MDSs are completed, locked with "EXPORT READY" status, and checks the said column in the MDS schedule. The Director of the Clinical Compliance and/or designee will transmit the "EXPORT READY" status MDSs to CMS. Upon completion of the transmission process in PCC, the RAUM Manager and/or designee checks the "ACCEPTED" column. A meeting with RAUM Managers and in-service regarding the transmission process will be conducted, and this audit will be done bi-weekly for two months, then bi-weekly for one month, and then monthly thereafter. This process will be monitored by the Director of MDS and/or designee. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? The MDS Schedule, the MDS report in PCC, and the IQIES report on MDS 3.0 Missing assessments will be utilized to complete the audit tool. The audit will be done by the Director of MDS or designee bi-weekly for one month, then monthly for three months. Results of the audits will be submitted to the Administrator, and results of the audits will be reported to the QAPI meeting monthly for three months for action as appropriate.
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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