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 Colorado. Pick another state for the same tag.
Against expectation — 2025
Colorado cites F838 less often than its own record predicts
Versus expected share0.44×
0.44 times the national share — cited less often here than elsewhere.
Share of Colorado citations0.11%
Of every deficiency written in Colorado in 2025, this is the portion that was F838.
Colorado0.11%
National0.25%
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 Colorado surveyors wrote
F838 findings written in Colorado, 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.
F · No harm, potential for more than minimal, widespreadMarch 12, 2026
Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies.Specifically, the facility failed to develop a facility assessment that was facility specific to include, resources, training and specifics about the resident population.Findings include:I. Record reviewThe facility assessment was provided by the nursing home administrator (NHA) on 3/12/26 at 11:00 a.m. The facility assessment revealed it was last reviewed on 5/8/25 by the NHA. …
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