Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 9 residents (Resident #121) reviewed for timing of assessments and was evidenced by the following: On 6/10/26, the surveyor reviewed the electronic medical records (EMR) of the residents in the Resident Assessment task which revealed: Resident #121 had a Quarterly MDS with a date of 2/5/26 was completed on 2/21/26 (due 2/19/26).On 6/11/26 at 10:54 AM, the surveyor interviewed the Regional MDS Coordinator (RMDSC), who stated Resident #121's MDS… …
F638 citations in New Jersey
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
New Jersey cites F638 more often than its own record predicts
2.00 times the share F638 takes of citations nationally.
Of every deficiency written in New Jersey 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 New Jersey surveyors wrote
F638 findings written in New Jersey, 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, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, for 3 of 21 residents (Residents #5, #7 and #14) reviewed for resident assessments. This deficient practice was evidenced by the following: 1). The surveyor reviewed the MDS information for Resident #5, contained within the electronic medical record. Further review revealed that the most recent MDS record for the referenced resident was created on 01/11/22, with an Assessment Reference Date (ARD, the end date for the observation period) of 01/27/22. The surveyor observed the Quarterly MDS was not completed. 2). …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 0.27× |
| 2024 | 0.25% | 1.45× |
| 2025 | 0.23% | 2.00× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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