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 North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F838 more often than its own record predicts
Versus expected share1.14×
1.14 times the share F838 takes of citations nationally.
Share of North Carolina citations0.29%
Of every deficiency written in North Carolina in 2025, this is the portion that was F838.
North Carolina0.29%
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 North Carolina surveyors wrote
F838 findings written in North Carolina, 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, isolatedFebruary 19, 2026
Based on record review and staff interviews, the facility failed to ensure the facility assessment identified and addressed the care required for the population of residents with a port-a-cath (a small implanted device placed under the skin in the chest to provide easy, long-term access to a vein for chemotherapy, medication, intravenous (IV) fluids, or blood sampling), and to address the staff training necessary to competently provide port-a-cath care for residents for 1 of 1 resident (Resident #1).Findings included:Review of the facility assessment revealed the assessment was last updated on 9/8/2025. …
C · No harm, potential for minimal, widespreadJuly 30, 2026
Based on staff interview and review of the Facility Assessment, the facility failed to have an accurate Facility Assessment that recorded the current administrative staff. This deficient practice had the potential to affect 58 of 58 residents. The findings included:The Facility Assessment was reviewed and was noted to have been updated and reviewed with the facility's Quality Assurance Performance and Improvement (QAPI) committee on 3/30/26. Page 1 of the Facility Assessment recorded the name of the former Administrator.An interview was completed on 7/30/26 at 4:45 PM with the facility's Administrator. The Administrator revealed he was not employed by the facility when the current Facility Assessment was reviewed and updated on 3/30/26. …
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