Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
of F838 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025274
Every F838 citation surveyors wrote nationally that year.
Facilities cited270
Distinct nursing homes with at least one F838 finding.
The harm level
How severely F838 is cited
0.6% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J10.1%
K10.1%
L10.1%
Actual harm
G30.3%
H—
I—
No harm, potential for more than minimal
D19319.4%
E15015.1%
F46546.7%
No harm, potential for minimal
A—
B272.7%
C15515.6%
Every recorded F838 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F838 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJanuary 14, 2026
Based on interviews and record review the facility failed to ensure the facility assessment dated [DATE] was updated appropriately and failed to identify staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The facility assessment did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. …
Based on observation, record review, and interviews conducted during an abbreviated survey (625460), the facility failed to ensure a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility did not consider specific staffing needs for each resident and adjust as necessary based on any changes to its resident population. This was evident during review of Staffing from 01/01/2024 - 01/06/2024. …
F · No harm, potential for more than minimal, widespreadAugust 31, 2026
Based on review of the Facility Assessment, medical record review, review of job descriptions, and staff interview, the facility failed to ensure the facility developed a comprehensive facility assessment to include active involvement from direct care staff, residents, resident representatives and family members within the facility assessment, and failed to address the education needs of staff caring for residents with tracheostomy tubes. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Findings include:1. …
B · No harm, potential for minimal, patternAugust 21, 2026
Based on interview and record review, the facility failed to determine the number of qualified staff needed to meet 40 out of 40 residents' day-to-day needs.The failure resulted in an incomplete Facility assessment (structured framework to evaluate the facility's resident population, operational resources, and overall care capabilities) which can result in poor healthcare outcomes. Findings: On 8/21/2026 at 10:54 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the Facility Assessment, updated 3/12/2026, was reviewed. The DON confirmed and stated the Facility assessment did not indicate the number of staff needed in their day-to-day operations.During a review of the Facility Assessment, 3/12/2026, the Assessment indicated:a. …
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Cited in the same inspection, not caused by one another.
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