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 District of Columbia. Pick another state for the same tag.
Against expectation — 2024
District of Columbia cites F838 more often than its own record predicts
Versus expected share7.86×
7.86 times the share F838 takes of citations nationally.
Share of District of Columbia citations1.53%
Of every deficiency written in District of Columbia in 2024, this is the portion that was F838.
District of Columbia1.53%
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 District of Columbia surveyors wrote
F838 findings written in District of Columbia, 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.
D · No harm, potential for more than minimal, isolatedAugust 8, 2024
Based on record review and staff interview, the facility's Administrator failed to conduct and document a facility-wide assessment annually to determine what resources are necessary to care for its residents competently during the day-to-day operations (including nights and weekends) and emergencies. The facility's census on the first day of the survey was 14.
The findings included:
Review of the facility's SNF (skilled nursing facility)-Administrative - 009 policy last reviewed in January 2020, documented in part:
- A facility assessment is conducted annually to determine and update SNF's capacity to meet the needs of and completely care for our residents during day-to-day operations. …
C · No harm, potential for minimal, widespreadJuly 16, 2024
Based on observation, record review and staff interview, facility staff failed to provide a facility-wide assessment that included the physical environment and space used for the resident's outdoor activities.
The findings included:
A review of the facility's assessment with a review date of 03/18/24 did not show documented evidence of the facility's (2) two outdoor patios currently being utilized for the 13 resident's who smoke at the facility.
During a face-to-face interview conducted on 07/16/24 at 3:00 pm, Employee #1 (Administrator) acknowledged the findings and stated, We have never included the smoking patios in our facility assessment.
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