Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set assessments were completed within the required 14 calendar days following the Assessment Reference Date and electronically encoded and transmitted to the Centers for Medicare and Medicaid Services within the required time frames for five of five residents (Residents #5, #15, #27, #32, and #42) reviewed for Minimum Data Set assessments. Specifically, quarterly Minimum Data Set assessments for Residents #5, #15, #27, #32, and #42 were not completed and submitted within 14 calendar days following the Assessment Reference Date. …
F636 citations in New York
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 York cites F636 more often than its own record predicts
1.47 times the share F636 takes of citations nationally.
Of every deficiency written in New York 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 York surveyors wrote
F636 findings written in New York, 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 reviews and interviews, the facility did not ensure that a comprehensive assessment of a resident was conducted in accordance with the required timeframes. This was evident for 15 (Resident #s 94, 17, 11, 41, 64, 140, 13, 17, 26, 37, 92, 46, 122, 103, 75) of 16 residents reviewed during the Resident Assessment Facility Task. Specifically, the admission and Annual assessments were not completed within 14 days of the Assessment Reference Date. The findings include but are not limited to: The facility policy titled, Minimum Data Set 3.0, last reviewed 01/2019, documented it is the policy of the facility to follow the guidelines of the most current State specific Resident Assessment Instrument manual correctly and effectively according to the Centers for Medicare and Medicare… …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.66× |
| 2024 | 0.25% | 0.84× |
| 2025 | 0.37% | 1.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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