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 Jersey. Pick another state for the same tag.
Against expectation — 2025
New Jersey 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 New Jersey citations0.50%
Of every deficiency written in New Jersey in 2025, this is the portion that was F838.
New Jersey0.50%
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 New Jersey surveyors wrote
F838 findings written in New Jersey, 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.
L · Immediate jeopardy, widespreadNovember 17, 2018
Based on interview, observation and record review, the facility failed to evaluate resident population and identify the resources needed to provide the necessary care and services required for residents during [MEDICAL CONDITION] outbreak. Specifically, 33 of 53 symptomatic residents tested positive for adenovirus (adenoviruses are a group of [MEDICAL CONDITION] that infect the lining of your eyes, airways and lungs, intestines, urinary tract, and nervous system and is a common cause of fever, coughs, sore throats, diarrhea, and pink eye) which resulted in 34 transfers to emergency room and/or hospitalization s and 11 deaths. …
F · No harm, potential for more than minimal, widespreadMarch 9, 2026
Based on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 107 residents who currently live in the facility.This deficient practice was evidenced by the following:During the entrance conference on 3/3/26 at 10:08 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). …
C · No harm, potential for minimal, widespreadDecember 16, 2022
Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the Facility Assessment included the resources required to establish policies and procedures for the management of an active COVID-19 (a potentially deadly virus) outbreak. This deficient practice was identified by the following.
Reference F880, F886
On 12/07/22 at 9:30 AM during the entrance conference, both the Administrator and the Director of Nursing (DON) stated that the facility was in an active outbreak of COVID-19 and confirmed that there were no active cases of COVID-19, or persons under investigation (PUI) for signs and symptoms of COVID-19. …
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