Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within required timeframes for two (2) of (2) residents reviewed for death in the facility tracking log. (Resident #10 and Resident #44). Findings include:Record review of the facility policy Minimum Data Set (MDS) Assessment Policy (JNH POL J550-43, [DATE]) revealed the following highlighted language: It is the policy of this facility to ensure that the MDS assessment is completed timely, accurately, and in accordance with all applicable Federal and State regulations The MDS Coordinator is responsible for coordinating, completing, and transmitting all MDS assessments in compliance with CMS requirements .All assessments will be submitted electronically to… …
F636 citations in Mississippi
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
Mississippi cites F636 less often than its own record predicts
0.38 times the national share — cited less often here than elsewhere.
Of every deficiency written in Mississippi 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 Mississippi surveyors wrote
F636 findings written in Mississippi, 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 record review, staff interview, and facility policy review, the facility failed to complete an Annual Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed. Resident # 24 Findings include Record review of the facility policy CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) . Chapter 5: Submission and Correction of the MDS Assessment, dated October 2023, revealed .5.2 Completion Timing: For all non-Admission OBRA (Omnibus Budget Reconciliation ACT) and PPS (Prospective Payment System) discharge assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference date (ARD) (A2300) . …
The short window
Recent years
| Year | Share of Mississippi citations | vs expected |
|---|---|---|
| 2023 | 0.67% | 1.71× |
| 2024 | 0.30% | 1.03× |
| 2025 | 0.10% | 0.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Mississippi surveyors cite →
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