Based on record review, staff interviews, and facility policy review, the facility failed to timely complete quarterly minimum data sets (MDS) within the time frame specified by Centers for Medicare and Medicaid Services (CMS) for three (3) of 21 minimum data sets reviewed. Resident #20, #41, #53Findings Include: Review of the facility policy titled “MDS/RAI (Resident Assessment Instrument) Standard” unrevised, revealed under, “Standard: This facility makes a comprehensive assessment of each resident’s needs, strengths, goals, life history and preferences using the RAI specified by CMS.” Resident #20 Record review of Resident #20’s Quarterly MDS with an Assessment Reference Date (ARD) of 7/26/25 revealed under section Z0500, the assessment had not been completed. …
F638 citations in Mississippi
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
Mississippi cites F638 more often than its own record predicts
1.68 times the share F638 takes of citations nationally.
Of every deficiency written in Mississippi 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 Mississippi surveyors wrote
F638 findings written in Mississippi, 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, staff interview, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed. Resident # 49 Findings include Record review of the facility policy CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) . Chapter 5: Submission and Correction of the MDS Assessment, dated October 2023, revealed .5.2 Completion Timing: For all non-Admission OBRA (Omnibus Budget Reconciliation ACT) and PPS (Prospective Payment System) discharge assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference date (ARD) (A2300) . …
The short window
Recent years
| Year | Share of Mississippi citations | vs expected |
|---|---|---|
| 2023 | 0.27% | 1.20× |
| 2024 | 0.30% | 1.75× |
| 2025 | 0.19% | 1.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Mississippi surveyors cite →
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