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F0637
D

Failure to Complete Significant Change MDS After Hospice Enrollment

Carlisle, Pennsylvania Survey Completed on 01-08-2026

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 comprehensive assessment following a significant change in condition for one resident. The resident’s clinical record showed diagnoses including hemiplegia and protein calorie malnutrition. The record further showed that hospice care was initiated on October 3, 2025, as documented on the Hospice Certification and Plan of Care. Review of the resident’s Minimum Data Set (MDS) revealed that no Significant Change MDS assessment had been completed since the resident entered hospice care, despite this representing a significant change in condition. In an interview on January 8, 2026, at 11:30 AM, the Nursing Home Administrator confirmed that a Significant Change MDS should have been completed within 14 days after the change in the resident’s status. This deficiency was cited under 28 Pa Code 211.12(d)(1)(5) related to nursing services.

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