of F636 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025271
Every F636 citation surveyors wrote nationally that year.
Facilities cited269
Distinct nursing homes with at least one F636 finding.
The harm level
How severely F636 is cited
0.1% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G10.1%
H—
I—
No harm, potential for more than minimal
D1,05973.3%
E29420.3%
F171.2%
No harm, potential for minimal
A—
B704.8%
C40.3%
Every recorded F636 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F636 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternJanuary 31, 2023
Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an additional 26 non-sampled residents with incomplete admission or annual MDSes. This failure was determined to be an immediate jeopardy situation because it put residents at risk for unmanaged medications, side effects from medications, skin conditions, and unknown needs that were never identified or addressed, which could have led to permanent injury, severe infection, and unknown potential harm due to the lack of comprehensive assessment. Findings include:
1. …
Based on interviews and record review, the facility failed to update a care plan for one of three residents (Resident 1) for the use of a Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers) the recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT). This failure resulted in a traumatic injury, of a right knee fracture for Resident 1.
Findings:
During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into Resident's 1 manual wheelchair. …
E · No harm, potential for more than minimal, patternSeptember 9, 2026
Based on interview and record review the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed within the required 14 calendar days for the following five residents: Resident (R)10, R41, R22, R18, and R27 Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of completed comprehensive MDS assessments for residents as follows: R10's 04/15/2026 Admission MDS was marked as In Progress (almost 5 months). R41's 05/04/2026 Admission MDS was marked as In Progress (over 4 months). R22's Annual MDS with an Assessment Reference Date (ARD) date of 06/24/2026, completed on 06/29/2026, and locked [to indicate completed] on 08/20/2026 (almost 2 months). …
B · No harm, potential for minimal, patternJuly 9, 2026
Based on facility documentation, facility policy, record review, and interviews for 2 of 6 residents (Resident#46 and Resident #70) reviewed for late Minimum Data Set (MDS) assessments, the facility failed to complete comprehensive MDS assessments timely. The findings include: 1. Resident #46 had a comprehensive admission MDS assessment with a completion date of 2/28/26.Review of documentation and record review identified that the admission MDS assessment was due on 2/14/26 and completed on 2/28/26 (14 days late).2. …
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Cited in the same inspection, not caused by one another.
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