Based on interview and record reviews, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 2 of 3 sampled residents (Resident #10 [R10] and R9). 1.Review of the RAI (Resident Assessment instrument) manual directs that a significant change MDS ARD (assessment reference date) date is no later than 14th calendar day after determination that significant change occurred. Completion is the 14th calendar day after determination. On 7/22/25 at 12:16 p.m., a review of R10's clinical record was completed. R10 was admitted to Hospice on 6/27/25 and a Significant Change MDS was initiated with an Assessment Reference Date (ARD) of 7/3/25 but was not completed. …
F637 citations in Maine
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maine cites F637 more often than its own record predicts
2.18 times the share F637 takes of citations nationally.
Of every deficiency written in Maine in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maine surveyors wrote
F637 findings written in Maine, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 calendar days after a resident experienced a significant change of condition and hospice services were initiated for 3 of 16 sampled residents (Resident #23, Resident #29, and Resident #31). Finding: The Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, page 2-23 reads that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. …
The short window
Recent years
| Year | Share of Maine citations | vs expected |
|---|---|---|
| 2023 | 0.32% | 1.03× |
| 2024 | 0.39% | 1.76× |
| 2025 | 0.52% | 2.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maine surveyors cite →
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