Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to utilize the Resident Assessment Instrument (RAI) to conduct a comprehensive and accurate assessment of residents' functional capacity for one (1) of thirty-three (33) sampled residents (Resident #13). The facility admitted Resident #13 on 09/14/15, with no deficits in range of motion (ROM). Review of Resident #13's Minimum Data Set assessments conducted from 09/26/15 through 12/05/18, revealed the resident was never assessed to have any limitations with Range of Motion (ROM) to the upper or lower extremities. …
F636 citations in Kentucky
Comprehensive assessments · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Kentucky cites F636 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky in 2025, this is the portion that was F636.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F636 findings written in Kentucky, 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.
Number of residents sampled: Number of residents cited: Based on facility policy review, record review, review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely for 2 Residents (R)23 and R40 of 2 residents reviewed for resident assessment requirements. The findings include: Review of facility policy titled, RAI Assessment-MDS 3.0 Completion, revised March 2025, revealed residents were assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 0.62% | 1.56× |
| 2024 | 0.15% | 0.51× |
| 2025 | 0.14% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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