Health inspection·August 21, 2025

CFR § 483.20 Resident assessment (f) Automated data processing requirement- (1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. (2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. (3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii)Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. (4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. CCR §72311 Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission CCR §72501 Licensee-General Duties (a) The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not diminish the responsibilities of such a licensee. On 8/6/2025, the California Department of Public Health (CDPH) received an anonymous complaint indicating the facility did not submit and transmit their residents’ Minimum Data Set (MDS-a resident assessment tool) to the Centers for Medicare and Medicaid Services (CMS- a federal and state program that provides and administers health insurance for those that qualify) since 8/2024. On 8/11/2024 CDPH conducted an unannounced visit to the facility to investigate the complaint and determined the facility failed to: 1. Ensure the required MDS data, including resident assessments, was electronically transmitted to the CMS System for all residents since August 2024. The facility has 163 licensed beds. On 8/11/2025 the residents’ census was 153 with six bed-holds. 2. Ensure that federally mandated residents’ assessment data, which is essential for care planning, quality measure reporting, and reimbursement accuracy, was electronically transmitted to the CMS since August 2024. 3. Implement the facility’s policy and procedure (P/P) titled, "Minimum Data Set 3.0 Assessment Completion, Transmission and Validation" undated, which indicated “the purpose is to establish that the facility uses an interdisciplinary approach to conduct and complete a comprehensive standardized assessment of each resident’s functional capacity and status, transmit and validate them as required. The MDS coordinator will transmit the file and print the initial and final Validation Report (a report that confirms the data submitted to CMS is accurate, complete, and follows the correct format, usually generated within 24 hours after submission). The MDS Coordinator will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepter Validation Report is received. To facilitate receiving validation Reports timely, the MDS coordinator will transmit as frequently as necessary to obtain timely Validation Report of MDS acceptance into the data base.”  These deficient practices resulted in the absence of federally mandated residents’ assessment data, which is essential for care planning, quality measure reporting, and reimbursement accuracy. The lack of submission affected all residents in Medicare/Medicaid-certified beds during this period, placing them at risk for inadequate care planning and inaccurate quality tracking. A review of the facility's MDS 3.0 NH Final Validation Report dated 7/31/2024 indicated this was the last verified transmitted report as of 8/11/2025. During an interview on 8/11/2025 at 10:20 a.m., the MDS coordinator stated that she just found out three weeks ago that CMS was not receiving any MDS data. The MDS coordinator stated currently the facility’s Information Technology (IT) staff (individuals responsible for managing and maintaining the computer systems, networks, software, and other technology that the organization uses) were working on transmitting the MDS data to CMS for the period from 8/2024 until 8/11/2025. During an interview on 8/11/2025 at 10:54 a.m., the MDS coordinator stated some of her job functions, included being responsible for reviewing, revising, and ensuring the MDS nursing assessment, evaluation of the residents’ health needs and their functional capabilities match the MDS data being transmitted to CMS. The MDS coordinator stated the last time the facility transmitted the MDS 3.0 NH and received Final Validation Report confirmation was on 7/31/2024.  The MDS coordinator stated the outcome of not submitting/transmitting the MDS assessments data in a timely manner is having outdated MDS assessments and care plans for the Residents which affects the accuracy of meeting residents’ needs.  During an interview on 8/11/2025 at 11:28 a.m., the Director of Nursing (DON), stated that some of his job functions included involvement in the process of hiring licensed nurses and oversee nursing operations while working with different departments regarding residents’ care. The DON stated last time the facility submitted MDS 3.0 NH Final Validation Report to CMS was in 7/2024. The DON stated that the negative outcome of not submitting/transmitting MDS assessments in a timely manner would result in having outdated care plans for the residents. The DON stated that it is important to have updated care plans because the care plans reflect the current and proper care the facility is providing for the Residents. The DON stated that it is the facility staff's responsibility to ensure that the MDS is transmitted and confirmation of a successful submission of the MDS 3.0 NH Final Validation Report is received. A review of the facility's P/P titled, "Minimum Data Set 3.0 Assessment Completion, Transmission and Validation," undated, indicated “the purpose is to establish that the facility uses an interdisciplinary approach to conduct and complete a comprehensive standardized assessment of each resident’s functional capacity and status, transmit and validate them as required. The MDS coordinator will transmit the file and print the initial and final validation report. The MDS Coordinator will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepter validation report tis received. To facilitate receiving Validation reports timely, the MDS coordinator will transmit as frequently as necessary to obtain timely validation of MDS acceptance into the data base.”  The facility failed to: 1. Ensure the required MDS data, including resident assessments, was electronically transmitted to the CMS System for all residents since August 2024. The facility has 163 licensed beds. On 8/11/2025 the residents’ census was 153 with six bed-holds. 2. Ensure that federally mandated residents’ assessment data, which is essential for care planning, quality measure reporting, and reimbursement accuracy, was electronically transmitted to the CMS since August 2024. 3. Implement the facility’s P/P titled, "Minimum Data Set 3.0 Assessment Completion, Transmission and Validation" undated, which indicated the purpose is to establish that the facility uses an interdisciplinary approach to conduct and complete a comprehensive standardized assessment of each resident’s functional capacity and status, transmit and validate them as required. The MDS coordinator will transmit the file and print the initial and final Validation Report. The MDS Coordinator will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepter Validation Report is received. To facilitate receiving Validation Reports timely, the MDS coordinator will transmit as frequently as necessary to obtain timely validation of MDS acceptance into the data base.”  These deficient practices resulted in the absence of federally mandated resident assessment data, which is essential for care planning, quality measure reporting, and reimbursement accuracy. The lack of submission affected all residents in Medicare/Medicaid-certified beds during this period, placing them at risk for inadequate care planning and inaccurate quality tracking. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of all residents in Medicare/Medicaid-certified beds during this period.