Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 1 resident (Resident #20) of 33 residents reviewed for MDS assessments.The findings include: Review of the MDS 3.0 RAI Manual version 20.1, dated 10/2025, revealed, .The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment .The MDS completion date for quarterly assessments must be no later than 14 days after the ARD [Assessment Reference Date] . …
F638 citations in Tennessee
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
Tennessee cites F638 more often than its own record predicts
3.02 times the share F638 takes of citations nationally.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F638 findings written in Tennessee, 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.
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2024 | 0.12% | 0.70× |
| 2025 | 0.35% | 3.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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