Based on review of clinical records, review of MDS (minimum data set- a federally required resident assessment completed at a specific interval) assessments, review of MDS schedules, review of MDS submission records and interview with staff, it was determined that the facility failed to complete comprehensive MDS assessment in a timely manner for 2 of 29 residents reviewed (Resident R107 and R108). Findings include: Review of facility policy on MDS (Minimum Data Set- Federally mandated resident assessment and care screening) Completion and Submission Time Frames With the most recent revision date of October 2023, revealed that under section Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. …
F636 citations in Pennsylvania
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
Pennsylvania cites F636 more often than its own record predicts
1.33 times the share F636 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F636 findings written in Pennsylvania, 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 review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R3, R6, R27, R15, R17, R20, and R37).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference… …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.40× |
| 2024 | 0.35% | 1.20× |
| 2025 | 0.33% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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