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 New Hampshire. Pick another state for the same tag.
Against expectation — 2025
New Hampshire cites F838 more often than its own record predicts
Versus expected share7.12×
7.12 times the share F838 takes of citations nationally.
Share of New Hampshire citations1.80%
Of every deficiency written in New Hampshire in 2025, this is the portion that was F838.
New Hampshire1.80%
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 New Hampshire surveyors wrote
F838 findings written in New Hampshire, 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.
D · No harm, potential for more than minimal, isolatedOctober 30, 2025
Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment determined the amount of time required to fulfill the role of the designated Infection Preventionist (IP).Findings include:Review on 10/29/25 of the facility's Facility Assessment, last reviewed 7/2025, revealed that there was no determination of the time required to fulfill the role of the IP in order to meet the residents' needs.Interview on 10/29/2025 at 12:02 p.m. with Staff M (Deputy Administrator) confirmed the above findings.
C · No harm, potential for minimal, widespreadJuly 16, 2026
Based on interview and record review, the facility failed to ensure that the facility assessment included specific direct care staffing needs for each unit and each shift such as day, evening, and night.Findings include: Review on 7/15/26 9:45 a.m. of the facility assessment, dated 2026, revealed that the facility assessment contained daily staffing numbers by discipline for the entire facility. It did not include information on the direct care staffing levels needed for each unit or each shift such as day, evening, and night. Interview on 7/15/26 9:45 a.m. with Staff F (Administrator) confirmed the above findings.
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