Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments within the required time frames for six residents (Residents #2, #7, #9, #16, #22, and #29) out of 12 sampled residents. This failure had the potential to affect the residents' comprehensive assessments and care planning. The facility's census was 29.Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2019, showed:- Assessments be completed and submitted according to federal and state requirements. …
F638 citations in Missouri
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
Missouri cites F638 less often than its own record predicts
0.46 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F638 findings written in Missouri, 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 interview and record review, the facility failed to ensure staff assessed residents using the Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff) no less frequently than every three months. This affected two of 13 sampled residents (Residents #1 and #3). The facility census was 39. 1. Review of Resident #3's MDS history showed: -Most recent annual assessment completed 7/17/17; -Quarterly assessment completed 10/19/17; -Quarterly assessment completed 1/19/18; -No other assessments completed past 1/19/18, with the next quarterly assessment due 4/19/18. Review of the resident's MatrixCare MDS print-out showed the resident's quarterly MDS dated [DATE] with a status of late, and no MDS completed on or after that date. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 2.19× |
| 2024 | 0.37% | 2.14× |
| 2025 | 0.05% | 0.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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