Based on interview and record review, the facility failed to complete non-comprehensive quarterly Minimum Data Set (MDS) assessments within the timeframe specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for six Residents (#34, #115, #3, #124, #138, and #105) out of a total sample of 24 residents. Specifically, the facility failed to complete non-comprehensive quarterly MDS Assessments for Residents #34, #115, #3, #124, #138, and #105 no later than 14 days following the assessment reference date (ARD). Findings include: Review of CMS' RAI Manual, dated October 2025, indicated non-comprehensive quarterly assessments are required to be completed no later than 14 calendar days following the ARD (ARD plus 14 calendar days). …
F638 citations in Massachusetts
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
Massachusetts cites F638 more often than its own record predicts
1.35 times the share F638 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F638 findings written in Massachusetts, 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 assess 6 Residents (#19, #22, #76, #81, #104 and #120) out of a total sample of 30 residents, using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid) not less frequently than once every 3 months. Findings iclude:1. Resident #19 was admitted to the facility in June 2025 with diagnoses including cancer, heart disease and anxiety. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 1/7/26. Further review indicated that a quarterly MDS dated [DATE] was still in progress. This is more than the 92-day completion date requirement between MDS assessments. 2. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.34% | 1.52× |
| 2024 | 0.18% | 1.06× |
| 2025 | 0.15% | 1.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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