Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment no later than 14 calendar days of the Assessment Reference Date (ARD, referring to the last day of the assessment period) for 1 of 36 sampled residents (Residents #13).Findings included:Resident #13 was admitted to the facility on [DATE].Review of Resident #13's electronic medical record revealed an annual MDS assessment dated [DATE] that was marked as completed on 06/03/26. The MDS assessment should have been completed on 05/20/26 (ARD plus 14 calendar days) but was not completed until 06/03/26 which made the assessment 14 days late.During an interview on 07/30/26 1:37 PM, the MDS Coordinator revealed she had been in her position since 10/05/25. …
F636 citations in North Carolina
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
North Carolina cites F636 more often than its own record predicts
2.50 times the share F636 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F636 findings written in North Carolina, 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 staff interviews, the facility failed to complete an annual Minimum Data Set (MDS) assessment within the required time frame for 1 of 19 residents reviewed for MDS assessments (Residents #9). The findings included: Resident #9 was admitted to the facility on [DATE]. A review of Resident #9's most recent MDS assessment was dated 7/12/24 and was coded as a annual assessment. The electronic medical record indicated the assessment was export ready and had not been transmitted. An interview was conducted on 08/07/24 at 11:48 AM with the MDS nurse. She stated the annual MDS assessments for Residents #9 had not been transmitted as required. She explained that there had been a lot of admissions and discharges, and she had gotten behind. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.77% | 1.95× |
| 2024 | 0.64% | 2.18× |
| 2025 | 0.63% | 2.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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