Based on record review and interviews conducted during survey, the facility failed to ensure timely completion of each resident's quarterly review assessments for 17 of 19 residents (Resident #s 25, 82, 115, 141, 184, 203, 211, 225, 255, 263, 275, 284, 356, 369, 383, 394, and 396) reviewed during the Resident Assessment Facility Task. Specifically, the residents' Quarterly Minimum Data Sets (a resident assessment tool) were not completed within 92 days after the previous Quarterly Minimum Data Set assessment and/or not signed off as completed within 14 days of the assessment start. …
F638 citations in New York
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 York cites F638 more often than its own record predicts
2.24 times the share F638 takes of citations nationally.
Of every deficiency written in New York 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 York surveyors wrote
F638 findings written in New York, 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 observation, record review, and interview, the facility failed to ensure quarterly Minimum Data Set assessments were completed within the required timeframe. This was evident in three (Residents #23, #59, and #225) of 13 residents reviewed for resident assessment. Specifically, the quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date.The findings include:The facility's policy and procedure dated 05/2026 titled Resident Assessment Instrument, Minimum Data Set, Care Area Assessment, Care Planning, Transmission, and Quality Assurance Policy required all Minimum Data Set assessments to be completed and transmitted in accordance with the timeframes established in the Centers for Medicare and Medicaid Services Resident Assessment… …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.42% | 1.86× |
| 2024 | 0.18% | 1.01× |
| 2025 | 0.26% | 2.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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