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 Indiana. Pick another state for the same tag.
Against expectation — 2025
Indiana cites F838 less often than its own record predicts
Versus expected share0.22×
0.22 times the national share — cited less often here than elsewhere.
Share of Indiana citations0.06%
Of every deficiency written in Indiana in 2025, this is the portion that was F838.
Indiana0.06%
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 Indiana surveyors wrote
F838 findings written in Indiana, 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, widespreadMay 21, 2026
Based on record review and interview, the facility failed to develop and maintain a comprehensive, facility-specific assessment that accurately identified and documented the staffing resources necessary to care for its resident population, including the specific number and ratio of staff required to meet resident needs. This deficient practice had the potential to affect 103 of 103 residents residing in the facility. Findings include:On 5/18/26 at 12:10 p.m., the Administrator provided a copy of the Facility Assessment. The assessment was reviewed and indicated the following statistics: an average resident population consisting of 185 admissions/stays, including 106 ongoing stays (57.3%), and 134 long-stay residents (72.4%). …
C · No harm, potential for minimal, widespreadJuly 14, 2022
Based on record review and interview, the facility failed to ensure the Facility Assessment Tool was up to date, accurate, and included thorough plans to address resource management and implementation of services provided. This deficient practice had the potential to effect 100 of 100 residents who resided in and received services from the facility.
Finding includes:
During the survey entrance conference, on 7/5/22 at 9:30 a.m., the most recent copy of the Facility Assessment tool was requested.
On 7/8/22 at 3:15 p.m., the Regional Risk Manager (RM) provided a copy of the Facility Assessment. The assessment was dated current through October 2021. …
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