Based on observation, interview, and record review, the facility's Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) failed to: 1. Thoroughly assess its resident population and its ability to provide care for residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself). 2. Evaluate and identify the needs of the resident in the behavioral health unit (BHU- section of the facility's building designated for residents with mental disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior] and memory care issues) located in Station 2 and the provision of behavioral health services to residents with suicidal… …
F838 citations in California
Facility assessment · Administration Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F838 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F838 findings written in California, 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 interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. …
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. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.36× |
| 2024 | 0.09% | 0.44× |
| 2025 | 0.23% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction