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 Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F838 less often than its own record predicts
Versus expected share0.53×
0.53 times the national share — cited less often here than elsewhere.
Share of Illinois citations0.13%
Of every deficiency written in Illinois in 2025, this is the portion that was F838.
Illinois0.13%
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 Illinois surveyors wrote
F838 findings written in Illinois, 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, widespreadJuly 10, 2026
Based on observation, interview and record review the facility failed to evaluate its resident population to prioritize its most vulnerable residents prior to a facility emergency. This failure has the potential to affect all 198 residents that reside in the facility.Findings include:On 7/2/26 at 9:33 AM, V2 (Director of Nursing) stated, we are going to send residents to sister facilities. The high acuity/risk residents move first. On 7/2/26 at 12:00 PM, observed clinical team: V2 (Director of Nursing), V25 (Vice President of Clinical Services), V26 (Registered Nurse Consultant), V27 (Regional Respiratory Director) preparing the list of vulnerable residents. V2 stated they are currently identifying vulnerable residents. …
C · No harm, potential for minimal, widespreadJuly 29, 2026
Based on interview and record review, the facility failed to 1) ensure active participation or solicit input from direct care staff in the development of the facility assessment, failed to solicit input from residents/their respective in the development of the facility assessment 2) failed to identify mandatory required training of the elements/goals of the facility's QAPI (Quality Assurance Performance Improvement) program 3) failed to consider staffing needs for each resident unit of the facility, failed to consider staffing needs for each resident shift of the facility 4) failed to identify/develop recruitment and retention program based on the facility assessment 5) identify/inform contingency planning for events that do not require activation of the facility's emergency plan, but do… …
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