Based on interview and record review, the facility failed to ensure that quarterly comprehensive assessments were completed no less frequently than once every 3 months for 2 of 2 residents (R) in the sample. As a result of this deficient practice, the facility placed R1 and R16 at risk of not having their needs met. This deficient practice has the potential to affect all the residents at the facility for long-term care. Findings include: On 09/21/23 at 03:00 PM, during a review of Resident (R)1's electronic health record (EHR), it was noted that R1's last quarterly Minimum Data Set (MDS) assessment had been completed on 05/20/23. The most recent MDS assessment showed an assessment reference date (ARD) or target date of 08/17/23, but had not been completed. …
F638 citations in Hawaii
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Hawaii cites F638 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Hawaii in 2023, this is the portion that was F638.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F638 findings written in Hawaii, 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.
What else Hawaii surveyors cite →
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