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 Kentucky. Pick another state for the same tag.
Against expectation — 2025
Kentucky cites F838 more often than its own record predicts
Versus expected share1.10×
1.10 times the share F838 takes of citations nationally.
Share of Kentucky citations0.28%
Of every deficiency written in Kentucky in 2025, this is the portion that was F838.
Kentucky0.28%
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 Kentucky surveyors wrote
F838 findings written in Kentucky, 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, patternFebruary 22, 2023
Based on observation, interview, and record review, it was determined the facility failed to conduct and document a facility-wide assessment to evaluate what resources were required to provide the necessary care and services for residents who required the use of a mechanical lift. On [DATE], staff transferred Resident #1 from a Geri chair to his/her bed utilizing the mechanical lift when the lift sling strap broke, and the resident fell to the concrete floor. Resident #1 fell approximately four (4) feet and sustained serious injuries which included fractures identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Resident #1 died related to his/her injuries from the fall. …
D · No harm, potential for more than minimal, isolatedMay 1, 2026
Based on observation, interview and review of the facility's assessment, the facility failed to implement the facility assessment dated [DATE], for the [NAME] Wing of the facility, which had the potential to affect all residents residing on the [NAME] Wing. The findings include: Review of the facility's Facility Assessment revealed the required staff at night for the [NAME] Wing of the facility, was supposed to have been two State Registered Nurse Aide (SRNA)'s. Review of the staffing schedule for the the week of 04/27/2026, revealed there had been only one SRNA scheduled for nights on the [NAME] Wing. In interview on 04/29/2026 at 10:00 AM, Resident (R)129 stated he had not slept well. …
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