Every finding on record at Corewell Health Rehabilitation & Nursing Center -

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) discharge assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) for 9 (Resident #24, #3, #18, #34, #16, #31, #1, #11, #32) of 9 sampled residents, resulting in the potential for inaccurate tracking of the resident's assessment and discharge status.Findings include: According to the CMS (Centers for Medicare & Medicaid Services) RAl (Resident Assessment Instrument) Version 3.0 Manual 1. 17.1. effective 10/1/2019, .Submission files are transmitted to the QIES [Quality Improvement and Evaluation System) ASAP (Assessment and Submission and Processing) system using the CMS wide area network .Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirement .must be submitted within 14 days of the MDS Completion Date (Z0500B +14 days] .For each file submitted, the submitter will receive confirmation that the file was received for processing and editing by the QIES ASAP system. This confirmation information includes the files submission identification number (ID), the date and time the file was received for processing as well as the file name . In an interview on 07/09/25 at 12:21 PM, MDS Coordinator (MC) F reported when the resident was discharging, there was a meeting once a week to discuss the resident who was ready to discharge, the resident was placed on a calendar at admission and was accessible to all relevant staff, who then can initial when they have completed their portion of the discharge, and a form noted as Discharge had the date of discharge and notations from all the relevant departments on what was needed prior to discharge. MC F reported the facility only had a handful of long term care residents; some residents stay for one quarterly assessment but the average stay for most residents was 21 days. Resident #24: Review of Resident #24's medical record revealed, Resident #24 was discharged from the facility. Review of MDS Assessments for Resident #24 revealed no MDS Discharge Assessment was submitted for acceptance by Centers for Medicare and Medicaid (CMS). MDS Coordinator (MC) F reported when the Discharge MDS Assessment indicated Ready for Export it indicated it had not been submitted to the (CMS MDS Program). In an interview on 07/09/25 at 12:47 PM, MDS Coordinator (MC) F reported the Care manager would send out an e-mail to the team which included the leadership team, and a discharge would be discussed at the weekly discharge meeting. MC F reported if the Discharge MDS Assessment was received by CMS it would indicate, Accepted. Reviewing Resident #24's MDS Discharge Assessment indicated the discharge date was 2/18/25 and the due date of 3/5/25 indicated when the Discharge MDS Assessment had to be completed by. MC F reported the Discharge MDS Assessment had been completed but not transmitted. MC F reported there was one MDS Coordinator who was responsible for the transmissions to (CMS MDS Program) and she completed the transmissions once per week. Resident #3: Review of Resident #3's medical record revealed, Resident #3 was discharged from the facility on 3/20/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. MC F showed this writer the Discharge document used to track each resident and for Resident #3 everything had been completed by the necessary staff within 24 hours of discharge. Resident #18: Review of Resident #18's medical record revealed, Resident #18 was discharged (return not anticipated) from the facility on 1/30/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. MC F reported the Discharge MDS Assessment was due 2/14/25. Resident #34: Review of Resident #34's medical record revealed, Resident #34 was discharged (return not anticipated) from the facility on 2/28/25 but the Discharge MDS Assessment was not completed for export or transmission. Resident #16: Review of Resident #16's medical record revealed, Resident #16 was discharged (return not anticipated) from the facility on 3/6/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. Resident #31:Review of Resident #31's medical record revealed, Resident #31 was discharged (return not anticipated) from the facility on 2/10/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. Resident #1:Review of Resident #1's medical record revealed, Resident #1 was discharged (return not anticipated) from the facility on 2/1/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. Resident #11: Review of Resident #11's medical record revealed, Resident #11 was discharged (return not anticipated) from the facility on 1/30/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. Resident #32: Review of Resident #32's medical record revealed, Resident #32 was discharged (return not anticipated) from the facility on 2/28/25. MC F reported the Discharge MDS Assessment was ready for export which indicated it had not been submitted for acceptance by CMS. In an interview on 07/09/25 at 12:57 PM, Director of Nursing (DON) B reported she monitored the MDS completion which ensured all sections of the MDS were completed for the resident for the 5 day, quarterly, and annual for MDS assessments. DON B reported the resident was added to a spreadsheet for tracking of assessments. DON B reported once the MDS were completed initially she would audit the medical record to ensure the care plans updated appropriately and the other MDSs were scheduled for completion. DON B reported she would ensure the schedule had the discharge scheduled but did not check to ensure the completion of the discharge and transmission of the Discharge MDS assessment.