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 Puerto Rico. Pick another state for the same tag.
Against expectation — 2024
Puerto Rico cites F838 more often than its own record predicts
Versus expected share3.62×
3.62 times the share F838 takes of citations nationally.
Share of Puerto Rico citations0.70%
Of every deficiency written in Puerto Rico in 2024, this is the portion that was F838.
Puerto Rico0.70%
National0.19%
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 Puerto Rico surveyors wrote
F838 findings written in Puerto Rico, 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, widespreadMay 21, 2026
Based on interviews and document review performed on 5/20/2026 at 3:30 PM, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents during operations and emergencies.Findings include:During entrance conference and interview with the Director of Operations (employee # 3), the facility assessment document was requested to be submitted within 4 hours after the entrance conference took place (05/20/2026 at 8:00 AM). The document was provided on 05/21/2026 at 3:30 PM.
C · No harm, potential for minimal, widespreadSeptember 25, 2024
Based on observations, staff interview and review of policies and procedures performed during the survey process from 09/24/2024 through 09/25/2024 from 8:30 AM through 4:30 PM it was determined that the facility failed to a required Facility Assessment. This deficient practice had the potential to affect 8 of 8 residents in the facility.
Findings include:
1. During the entrance conference performed on 09/24/2024 at 9:00 AM with the Administrator, the surveyors request the facility assessment, as one of the documents that they must provide within four hours of the entrance conference.
2. On 09/25/2024 at 2:30 PM during interview the Administrator (employee #3) stated that facility is in the process of development of the facility assessment.
3. …
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