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 Georgia. Pick another state for the same tag.
Against expectation — 2025
Georgia cites F838 less often than its own record predicts
Versus expected share0.45×
0.45 times the national share — cited less often here than elsewhere.
Share of Georgia citations0.11%
Of every deficiency written in Georgia in 2025, this is the portion that was F838.
Georgia0.11%
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 Georgia surveyors wrote
F838 findings written in Georgia, 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, patternMay 1, 2023
Based on record review and staff interview, the facility failed to conduct and document a facility wide assessment that included and documented all required components of the resident population and facility resources. The facility census was 211.
On 4/25/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. …
F · No harm, potential for more than minimal, widespreadMarch 13, 2026
Based on interview, record review, and policy review, the facility failed to review and update the facility assessment annually. This failed practice had the potential to affect all 59 residents to ensure every resident received necessary care and services. Findings include:Review of the facility's Facility Assessment Tool, dated, 06/30/25, revealed, .current population as of 06/30/24.During an interview on 03/12/26 at 1:30 PM, the Administrator confirmed the facility assessment was dated 06/30/25, the report is based on the past 12 months and the current population was dated as of 06/30/24. He stated it was an error that all the dates were not updated when the assessment was completed. …
C · No harm, potential for minimal, widespreadDecember 18, 2022
Based on record review and staff interview, the facility failed to develop an individualized facility assessment that addressed staffing within the facility. Specifically, the facility failed to develop a facility specific assessment that included an individualized approach to determine staffing levels and an evaluation of the overall number of facility staff needed to ensure the resident's needs are met.
Findings included:
Review of the Facility assessment dated [DATE] through 12/16/22 revealed that the assessment did not include a facility specific approach to determine the staffing levels needed in the facility. …
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