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 Michigan. Pick another state for the same tag.
Against expectation — 2025
Michigan cites F838 less often than its own record predicts
Versus expected share0.73×
0.73 times the national share — cited less often here than elsewhere.
Share of Michigan citations0.19%
Of every deficiency written in Michigan in 2025, this is the portion that was F838.
Michigan0.19%
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 Michigan surveyors wrote
F838 findings written in Michigan, 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.
I · Actual harm, widespreadFebruary 3, 2022
Based on interview, and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment of the physical environment, equipment, training programs, policies/procedures, and health information technology resources, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.
Findings:
Review of the Facility Assessment, updated 8/2/21, revealed no comprehensive evaluation of the facility's training program. Under the section Staff Training/Education and Competencies. …
F · No harm, potential for more than minimal, widespreadJune 24, 2026
Based on interview and record review, the facility failed to incorporate the key components of staffing needs for each resident unit and staffing needs for each shift, into their facility assessment potentially affecting all 109 residents residing in the facility. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.The facility assessment, last updated 2/12/2026, was reviewed. This document indicated the assessment was completed at the facility level to serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources.The section titled INFORMATION ABOUT NURSE STAFFING PLANS included a table with the heading of Overall Staffing Needs. …
C · No harm, potential for minimal, widespreadMay 16, 2024
Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.
Findings include:
Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 10/12/22.
In an interview on 5/16/24 at 11:05 AM, Interim Nursing Home Administrator (NHA) A reported he had only been at the facility since April 2024. Interim NHA A reported he had contacted the former NHA who confirmed the Facility Assessment had not been completed, updated, or reviewed since 10/12/22. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction