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.
F838 in Alabama. Pick another state for the same tag.
Against expectation — 2024
Alabama cites F838 more often than its own record predicts
Versus expected share1.88×
1.88 times the share F838 takes of citations nationally.
Share of Alabama citations0.36%
Of every deficiency written in Alabama in 2024, this is the portion that was F838.
Alabama0.36%
National0.19%
Share of all citations that were F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alabama surveyors wrote
F838 findings written in Alabama, 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.
K · Immediate jeopardy, patternAugust 4, 2018
Based on interviews and review of the CENTER ASSESSMENT TOOL, the facility failed to address the care and services, as well as staff competencies, necessary to provide care to the residents who reside on the 35-bed secured Alzheimer's Care Unit. This deficient practice affected all 28 residents who reside on the secured Alzheimer's Care Unit and placed these residents in immediate jeopardy for serious injury, harm or death.
On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F838. …
E · No harm, potential for more than minimal, patternJune 3, 2024
Based on interviews, record review and a review of the Facility Assessment, the facility failed to ensure the facility assessed addressed substance abuse, smoking and vaping. The facility's most current Facility assessment dated [DATE] did not identify the need for staff competencies regarding substance abuse.
This deficient practice had the potential to affect 86 of 86 residents.
These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176.
Findings include:
RI #286 was admitted to the facility on [DATE]. RI #286 had diagnoses that included Paraplegia, Muscle weakness, and Stimulant Dependence.
RI #286 Admission Minimum Data Set (MDS) dated [DATE] assessed by MDS #6, revealed a Brief Interview for Mental Status (BIMS) score 15. …
C · No harm, potential for minimal, widespreadNovember 29, 2018
Based on interview and a review of a facility document titled, Facility Assessment, the facility failed to evaluate and identify areas of the environment needing to be maintained.
This deficient practice had the potential to affect all 134 residents residing in the facility.
Findings Include:
Cross Reference F584.
A review of a document titled, Facility Assessment, dated 11/19/18, revealed the following: .The following criteria were examined and evaluated by our team .
Physical environment .considerations necessary for resident population.
Equipment necessary for resident population . …
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