Based on a review of Resident Assessments Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessments for one of three samples residents (Resident R41).Findings include: Review of Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated [DATE], indicated the significant change assessments (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. …
F637 citations in Pennsylvania
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
Pennsylvania cites F637 more often than its own record predicts
1.26 times the share F637 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F637 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 significant Change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) were completed in the required time frame for three of five residents (Resident R42, R69, and R79). 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 2019, indicated that a Significant Change in Status assessment be completed by the 14th calendar day after… …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.32% | 1.03× |
| 2024 | 0.22% | 0.99× |
| 2025 | 0.30% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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