Based on interview and document review the facility failed to ensure quarterly Minimum Data Set (MDS) was completed in a timely manner for 1 of 1 residents (R39) reviewed for MDS completion. Findings include:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified a Quarterly Assessment is a non-comprehensive assessment required no later than 92 days after the previous assessment of any type to monitor gradual changes in the resident's condition between comprehensive assessments.R39's Face Sheet located in the facility's electronic medical record (EMR) indicated an initial admission date of 3/18/24.R39's MDS dated [DATE], identified moderate cognitive impairment and diagnoses that included… …
F638 citations in Minnesota
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
Minnesota cites F638 more often than its own record predicts
1.36 times the share F638 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F638 findings written in Minnesota, 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.
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.86× |
| 2025 | 0.16% | 1.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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