Based on interviews and record review, the facility failed to complete comprehensive assessments in the timeframe specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for six Residents (#5, #133, #82, #98, #122 and #9) out of a total sample of 24 residents.Specifically, the facility failed to ensure that:1.annual Minimum Data Set (MDS) assessments were completed for Residents #5, #133, #82 and #98 no later than 14 days after the MDS assessment reference dates (ARDs).2. significant change in status assessments (SCSAs) were completed for Residents #122 and #9 no later than 14 days after determination that significant change in the Residents' status occurred, resulting in both Residents being admitted to hospice services. …
F636 citations in Massachusetts
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
Massachusetts cites F636 less often than its own record predicts
0.62 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F636 findings written in Massachusetts, 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 observation, record review, and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process, for one Resident (#3) out of a total sample of 28 residents.Specifically, the facility staff failed to assess Resident #3's cognitive status and mood through the required resident interview process when the Resident had difficulty with communication and a fluctuating ability to communicate. Findings include:Resident #3 was admitted to the facility in August 2024 with diagnoses including Multiple Sclerosis, Hemiplegia and Hemiparesis and locked-in state. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 1.24× |
| 2024 | 0.21% | 0.73× |
| 2025 | 0.15% | 0.62× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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