Based on interview and record review, the facility did not assess a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 1 of 17 residents (R7).-R7's Quarterly MDS assessment was completed 40 days late and not submitted to CMS until survey was in process.Findings include:The facility policy titled, Resident Assessments, last revised October 2025, states the resident assessment coordinator (RAC) is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.R7 was admitted to the facility on [DATE].R7's Minimum Dat Set (MDS) assessments indicated an assessment with an Assessment Reference Date (ARD) of 04/19/26 was… …
F638 citations in Wisconsin
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
Wisconsin cites F638 less often than its own record predicts
0.95 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F638 findings written in Wisconsin, 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 Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.28% | 1.24× |
| 2024 | 0.07% | 0.40× |
| 2025 | 0.11% | 0.95× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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