Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 2 of 10 residents (Resident #22 and Resident #153) reviewed for timing of assessments and was evidenced by the following: On 6/10/26, the surveyor reviewed the electronic medical records (EMR) of the residents in the Resident Assessment task which revealed:Resident #22 had an annual MDS with a date of 3/19/26 which was completed on 4/6/26 (due 4/2/26). …
F636 citations in New Jersey
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
New Jersey cites F636 more often than its own record predicts
2.02 times the share F636 takes of citations nationally.
Of every deficiency written in New Jersey 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 New Jersey surveyors wrote
F636 findings written in New Jersey, 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, it was determined that the facility failed to complete the Comprehensive Minimum Data Set assessment in a timely manner for 8 residents. This deficient practice was identified for Residents #11, #10, #17, #54, #6, #13, #27, and #736, 8 of 78 residents reviewed for comprehensive assessments and was evidenced by the following: Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/2021, the surveyor reviewed the electronic medical record (EMR) for resident #11. The Comprehensive Minimum Data Set (MDS), an assessment tool completed on admission and annually, revealed an Assessment Reference Date (ARD), a date used as the last day of a look-back period, of 9/4/2021. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 0.62× |
| 2024 | 0.25% | 0.86× |
| 2025 | 0.50% | 2.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction