Based on observation, record review, and interviews conducted during an abbreviated survey (625460), the facility failed to ensure a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility did not consider specific staffing needs for each resident and adjust as necessary based on any changes to its resident population. This was evident during review of Staffing from 01/01/2024 - 01/06/2024. …
F838 citations in New York
Facility assessment · Administration Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New York cites F838 more often than its own record predicts
3.19 times the share F838 takes of citations nationally.
Of every deficiency written in New York in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New York surveyors wrote
F838 findings written in New York, 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.
Based on record review and interviews conducted during the abbreviated survey, the facility failed to ensure that the Facility Assessment thoroughly assessed the needs of the resident population and determined the resources necessary to care for residents competently during day-to-day operations, including nights and weekends. Specifically, the Facility Assessment did not address what was considered sufficient staffing, particularly on weekends, and how the care required on a weekend shift differed from the care required on weekdays. …
Based on observation, interview, and record review during the survey, the facility failed to accurately document the resident population, the overall acuity, the care required by the resident population, and the resources needed, in the facility assessment. This was identified for one (Unit 1C) of eight nursing units reviewed for sufficient and competent nurse staffing task. Specifically, the facility has a dedicated ventilator unit with certified ventilator beds, occupied by ventilator dependent residents who receive ventilator-related respiratory care. The facility assessment did not include the ventilator dependent residents to determine what resources were necessary to care for those residents including the use of competent and qualified Respiratory therapists. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 1.54× |
| 2024 | 0.46% | 2.34× |
| 2025 | 0.81% | 3.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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