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 Oklahoma. Pick another state for the same tag.
Against expectation — 2025
Oklahoma cites F838 less often than its own record predicts
Versus expected share0.64×
0.64 times the national share — cited less often here than elsewhere.
Share of Oklahoma citations0.16%
Of every deficiency written in Oklahoma in 2025, this is the portion that was F838.
Oklahoma0.16%
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 Oklahoma surveyors wrote
F838 findings written in Oklahoma, 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.
F · No harm, potential for more than minimal, widespreadJune 10, 2026
Based on record review and interview, the facility failed to ensure a facility assessment had been completed annually. The DON identified 25 residents resided in the facility. Findings: An undated policy titled Facility Assessment Policy and Review Procedure showed quarterly reviews shall be maintained and reported through QAPI, and a comprehensive review shall be conducted annually. On 06/08/26 at 10:22 a.m., the administrator stated the most current facility assessment located was dated 08/24/18. There was no documentation the facility assessment had been updated annually. On 06/09/26 at 9:15 a.m., the administrative assistant provided a facility assessment dated [DATE].
C · No harm, potential for minimal, widespreadJuly 19, 2024
Based on record review and interview, the facility failed to ensure a facility assessment was updated annually.
The DON identified 101 residents resided in the facility.
Findings:
A Facility Assessment Tool, documented the date of assessment or update was 11/21/17. It documented the date the facility assessment was reviewed with QAA/QAPI was 12/13/17.
On 07/19/24 at 9:23 a.m., the Administrator stated the facility assessment was to be updated annually.
On 07/19/24 at 9:27 a.m., the Administrator stated their process was to change any information that required to be updated in the facility assessment.
On 07/19/24 at 9:29 a.m., the Administrator reviewed the facility assessment. They stated according to you it has not been updated.
48344
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction