Based on observations, staff interviews, and review of the facility policies titled, MDS Compliance, and Center for Medicare Services Resident Assessment Instrument Manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in status for one of 29 sampled residents (R) (R9). The deficient practice placed R9 at risk of unassessed and unplanned care needs.Findings include: Review of the policy titled, MDS Compliance reviewed 12/27/2025, section titled, Guideline, documented, .Centers will complete a Significant Change in Status MDS Assessment when a major decline or improvement in a resident's status is identified by the Interdisciplinary Team. …
F637 citations in Georgia
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F637 less often than its own record predicts
0.95 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F637 findings written in Georgia, 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 staff interviews and record review the facility failed to complete a significant change Minimum Data Set (MDS) assessment, within fourteen days of the significant change, for one resident (R) (R11), who was discharged from hospice service, out of 11 resident records reviewed. Findings included: Review of R11's Electronic Medical Record (EMR) revealed an admitted [DATE] with diagnoses of, but not limited to, chronic obstructive pulmonary disease, neurocognitive disorder with Lewy bodies disease, and Parkinson's disease. Review of R11's MDS significant change assessment dated [DATE] revealed Section documented the resident was assessed as receiving hospice services while a resident at the facility. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.09% | 0.28× |
| 2024 | 0.20% | 0.90× |
| 2025 | 0.23% | 0.95× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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