Based on record reviews and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #11).The findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur (thigh bone) with routine healing, disorientation, and atrial fibrillation (an abnormal heart rhythm). A medical record review revealed Resident #11 was admitted to Hospice on 12/09/25 with a primary hospice admission diagnosis of senile degeneration of the brain (a progressive cognitive decline in older adults).A review of Resident #11's MDS assessments revealed significant change in status MDS assessment was not completed during the required… …
F637 citations in North Carolina
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
North Carolina cites F637 more often than its own record predicts
1.61 times the share F637 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F637 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 review and staff interviews, the facility failed to complete the required Significant Change in Status Assessment (SCSA) for 1 of 19 residents (Resident #32) reviewed for assessments. Resident #32 required a SCSA due to changes in activities of daily living (ADL). Findings included: Resident #32 was admitted to the facility on [DATE]. Diagnoses included major joint replacement with right femur fracture. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 was moderately cognitively impaired and required extensive assistance with two staff physical assistance with bed mobility, supervision with one staff physical assistance with transfers, and eating, and extensive assistance with one staff physical assistance with toileting. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.34% | 1.10× |
| 2024 | 0.44% | 1.95× |
| 2025 | 0.39% | 1.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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