Based on review of clinical records, review of MDS (minimum data set- a federally required resident assessment completed at a specific interval) assessments, review of MDS schedules, review of MDS submission records and interview with staff, it was determined that the facility failed to complete the required Quarterly MDS assessments within the required timeframe (at least every 92 days) for 5 of 29 residents reviewed (Resident R30, R81, R7, R163, and R177). Findings include: Review of facility policy on MDS (Minimum Data Set - federally mandated resident assessment and care screening) Completion and Submission Time Frames With the most recent revision date of October 2023, revealed that under section Statement: Our facility will conduct and submit resident assessments in accordance with… …
F638 citations in Pennsylvania
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
Pennsylvania cites F638 more often than its own record predicts
1.72 times the share F638 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F638 findings written in Pennsylvania, 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 review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for five of 20 residents (Residents R20, R34, R39, R42, and R43).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.22% | 0.99× |
| 2024 | 0.20% | 1.13× |
| 2025 | 0.20% | 1.72× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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