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F0637
D

Failure to Timely Complete Significant Change MDS Assessment After Hospice Admission

T Or C, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released
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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 Minimum Data Set (MDS) assessment within the required 14-day timeframe after a major change in a resident's condition. Specifically, a resident was admitted to hospice care as ordered by the physician, indicating a significant change in health status. However, the significant change MDS assessment was not signed off by the RN until several weeks later, exceeding the 14-day requirement. This was confirmed by both record review and interview with the MDS coordinator, who acknowledged the assessment was not completed within the mandated period.

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