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 Minnesota. Pick another state for the same tag.
Against expectation — 2025
Minnesota cites F838 more often than its own record predicts
Versus expected share2.00×
2.00 times the share F838 takes of citations nationally.
Share of Minnesota citations0.50%
Of every deficiency written in Minnesota in 2025, this is the portion that was F838.
Minnesota0.50%
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 Minnesota surveyors wrote
F838 findings written in Minnesota, 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 16, 2026
Based on interview and document review, the facility failed to ensure the Facility Assessment included information on staffing levels needed for specific shifts. This deficient practice had the potential to affect all 42 residents who resided in the facility.Findings include:Review of Facility assessment dated 6/2026, indicated the following:Section 3. Facility resources needed to provide competent support and care for our resident population every day and during emergencies:3.2 & 3.3. Direct Care Staffing Plan: To ensure an adequate amount of staff at Lakeshore Rehabilitation Center at all times, the resident population, case mix index (CMI), and census if taken into account daily to determine sufficient staffing needs. …
C · No harm, potential for minimal, widespreadAugust 17, 2026
Based on interview and record review the facility failed to ensure its facility assessment accurately reflected its current resident's population. The facility assessment did not identify the 37 residents with substance use disorders (SUD) or identify the related care and services needed of this population in the facility. Although the facility provided the staff education addressing SUD and mental health through online training, the facility assessment did not accurately reflect the population requiring these services.Findings include: The facility assessment with a revision date of 1/2026 indicated:Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care included:Psychiatric/mood disorders… …
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