F638 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F638 more often than its own record predicts
Versus expected share1.68×
1.68 times the share F638 takes of citations nationally.
Share of North Carolina citations0.19%
Of every deficiency written in North Carolina in 2025, this is the portion that was F638.
North Carolina0.19%
National0.11%
Share of all citations that were F638.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F638 findings written in North Carolina, 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.
D · No harm, potential for more than minimal, isolatedMay 15, 2026
Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 1 of 28 sampled residents reviewed (Residents #2). Findings included:Resident #2 was admitted to the facility on [DATE].Review of Resident #2's electronic medical record revealed a quarterly MDS assessment with an ARD of 04/03/26 that was marked as completed on 04/20/26.During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator verified Resident #2's quarterly MDS assessment dated [DATE] was not completed within the regulatory time frame. …
B · No harm, potential for minimal, patternSeptember 13, 2025
Based on staff interviews and record reviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 8 of 54 residents whose MDS assessments were reviewed (Residents #31, #10, #92, #7, #109, #78, #52 and #85).
8. Resident #85 was admitted to the facility 9/8/23.
Review of the medical record on 9/10/25 revealed the quarterly MDS assessment had an Assessment Reference Date (ARD) of 6/26/25. The assessment was signed as completed by the facility's Registered Nurse MDS coordinator on 8/15/25.
An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. …
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