Based on record review and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments were completed no greater than 92 days from the most recent prior quarterly review for 14 of 16 residents' records reviewed and 19 of 19 quarterly assessments reviewed which had the potential to affect all residents living in the facility.Findings include:A review of facility policy titled MDS 3.0 Completion implemented on 10/1/25 without review or revision dates revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: . e. …
F638 citations in South Carolina
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 — 2023
South Carolina cites F638 more often than its own record predicts
2.11 times the share F638 takes of citations nationally.
Of every deficiency written in South Carolina in 2023, 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 South Carolina surveyors wrote
F638 findings written in South 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.
Based on record review and interview, the facility failed to complete an MDS (Minimal Data Set) Assessment within 92 days of the prior MDS assessment for Resident #10, 1 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #10 on 08/14/17 with [DIAGNOSES REDACTED]. On 09/05/18 at approximately 2:35 PM, review of the State Agency MDS data base revealed an Annual MDS assessment dated [DATE]. Further review revealed a discharge MDS assessment dated [DATE] and a Re-entry MDS dated [DATE]. No Quarterly MDS Assessment, with an Assessment Reference Date no later than 08/11/18 was noted. …
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