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 Mississippi. Pick another state for the same tag.
Against expectation — 2025
Mississippi cites F838 more often than its own record predicts
Versus expected share1.90×
1.90 times the share F838 takes of citations nationally.
Share of Mississippi citations0.48%
Of every deficiency written in Mississippi in 2025, this is the portion that was F838.
Mississippi0.48%
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 Mississippi surveyors wrote
F838 findings written in Mississippi, 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.
J · Immediate jeopardy, isolatedJanuary 14, 2026
Based on interviews and record review the facility failed to ensure the facility assessment dated [DATE] was updated appropriately and failed to identify staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The facility assessment did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. …
F · No harm, potential for more than minimal, widespreadApril 2, 2026
Based on record review, staff interview, and facility policy review, the facility failed to develop and maintain a comprehensive facility assessment to determine the appropriate number of qualified staff needed to meet residents' needs, including sufficient licensed nursing staff coverage, affecting (89) of (89) residents in the facility. Findings include:A review of the facility's policy, Facility Assessment, revised June 2024, revealed, .Facility Assessment.4. The facility assessment is used to inform staffing decisions. a. The assessment is used to ensure there is enough staff with appropriate competencies and skill sets to meet the needs of the residents identified through the review of resident assessments and plans of care.b. …
C · No harm, potential for minimal, widespreadApril 4, 2019
Based on interview and record review, the facility failed to ensure Legionella (a severe form of pneumonia caught by inhaling bacteria) and other waterborne pathogens polices were incorporated into the facility assessment. This had the potential to affect all 47 residents residing in the facility.
Findings include:
A Standards and Certification (S&C) memorandum dated as revised 06/09/17 from the Centers of Medicare Services (CMS) stated, .Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression. …
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