Based on interview, record review and document review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 3 of 32 sampled residents (Resident 21, 50, and 58). The deficient practice had the potential to delay the development and implementation of a person-centered care plan for the residents.Findings include:1) Resident 21 (R21) was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, tracheostomy status, gastrostomy status, and dependence on respirator (ventilator) status.R21's medical record contained the list of quarterly MDS with assessment reference date (ARD/the end date of an observation or look-back period for an MDS assessment)… …
F638 citations in Nevada
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
Nevada cites F638 more often than its own record predicts
1.43 times the share F638 takes of citations nationally.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F638 findings written in Nevada, 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 clinical record review, interview and document review, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed or submitted timely for the months of February, March, April, May, June, July, September, and October 2023. Findings include: On 12/13/23 at 9:29 AM, the Regional Minimum Data Set (MDS) Registered Nurse (RN) confirmed the late completion of 14 of 112 assessments for February 2023 with a total error percentage of 12.50, and 17 of 150 assessments for March 2023 with a total error percentage of 11.33. The Regional MDS RN verbalized due to staff turnover the completion error rate had increased for the months of February and March 2023 and the Regional MDS RN was now overseeing the completion of the resident assessment process. …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.83× |
| 2025 | 0.16% | 1.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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