A resident’s discharge return anticipated MDS was not completed and transmitted in a timely manner after discharge. The MDS Coordinator confirmed the tracking assessment was late and did not know why, while the DON confirmed the resident appeared on the missing assessment report. The RAI Manual requires discharge MDS completion and transmission within specified timeframes.
The facility failed to timely submit discharge MDS assessments for two residents. Record review showed both discharge assessments were completed but not submitted, and the MDS Coordinator stated the CMS submission coding had not been updated. The DON stated MDS assessments were expected to be submitted timely after completion.
Failure to Transmit Completed MDS: A resident’s DRNA MDS was completed but not transmitted within the required timeframe. The RN/MDSC confirmed the MDS should have been sent and was unsure of the applicable deadline, and later stated there were no transmission reports because it had not been transmitted. The DON and LNHA were notified of the finding.
A resident was discharged from the facility, but the MDS record did not include a discharge assessment. Survey review found the last MDS on file was a quarterly assessment, and the MDS Coordinator confirmed the discharge MDS was missed. The LNHA later acknowledged that no discharge MDS had been completed for the resident at discharge.
The facility failed to transmit completed MDS assessments correctly for 17 reviewed residents. The MDSs were completed but submitted only as state-only assessments instead of being transmitted to CMS, and the DON and Administrator stated they were not aware of the error until the surveyor inquiry. As a result, the residents were not showing up for the provider.
A facility failed to complete and submit a discharge MDS tracking form within 14 days for a resident with multiple diagnoses, including clostridium difficile and pressure ulcers. The MDS Coordinator and DON acknowledged the requirement, but the discharge MDS was not completed in the required timeframe, contrary to facility policy and RAI manual standards.
A facility failed to complete and transmit the MDS for a resident within the required timeframe post-discharge. The MDS was not completed within 14 days as required, and the MDS Coordinator was unsure of the reason for the delay. The deficiency was identified during a review of MDS records over 120 days old.
The facility failed to complete and transmit MDS assessments within the required 14 days for multiple residents, as identified by surveyors through interviews and record reviews. The MDSC/RN confirmed the delays, citing workload issues, and the facility relied on the RAI manual for guidelines without a separate policy. Meetings with the LNHA and DON did not yield additional information or corrective actions.
The facility failed to transmit MDS assessments for 17 residents within the federally mandated 14-day period. Despite attempts to submit weekly, the assessments were delayed by over 120 days. The MDS Coordinator acknowledged the issue, and the facility's policy did not address MDS data transmission.
A facility failed to complete and transmit a Minimum Data Set (MDS) death in facility tracking record for a resident who expired, as required by federal guidelines. The MDS Coordinator confirmed that the record was not completed or transmitted, despite the facility's policy requiring timely submission in accordance with federal and state timeframes.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account