Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. Record review and staff interviews confirmed that the resident was admitted to hospice with an effective order date of 4/21/25, but the Significant Change in Status MDS assessment was not completed and signed until 5/7/25, which was outside the mandated period. This deficiency was identified during a survey and was based on the review of medical records and provider orders for the resident involved in hospice care. The MDS is a federally mandated assessment tool used to guide care planning decisions, and timely completion is required when there is a significant change in a resident's status, such as admission to hospice. The failure to complete the assessment within the specified timeframe was evident in the documentation reviewed for the resident.