Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 1 residents reviewed for Resident Assessment. (Resident 6)Finding includes: On 4/6 at 11:26 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, disorder of the kidney and ureter and essential primary hypertensionThe most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] but was not completed until 4/10/26. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director indicated care plan conferences needed to be done every 3 months.On 4/17/26 at 10:40 A.M., the Administrator provided a current policy Care Planning dated 2/2026. The policy indicated . …
F638 citations in Indiana
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 — 2025
Indiana cites F638 less often than its own record predicts
0.74 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana in 2025, 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 Indiana surveyors wrote
F638 findings written in Indiana, 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 interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 6 of 19 residents whose MDS assessments were reviewed. (Residents 8, 25, 29, 17, 19, and 42) Findings include: 1. The Resident Assessment Task MDS tracking data indicated Resident 8's last MDS assessment was over 120 days old. Record review for Resident 8 was completed on 1/10/24 at 9:12 a.m. An Annual Minimum Data Set (MDS) assessment was completed on 8/23/23. The Quarterly MDS assessment, dated 11/22/23, had multiple incomplete sections and indicated it was in process. 2. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 0.67× |
| 2024 | 0.13% | 0.75× |
| 2025 | 0.08% | 0.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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