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 Tennessee. Pick another state for the same tag.
Against expectation — 2025
Tennessee cites F838 less often than its own record predicts
Versus expected share0.91×
0.91 times the national share — cited less often here than elsewhere.
Share of Tennessee citations0.23%
Of every deficiency written in Tennessee in 2025, this is the portion that was F838.
Tennessee0.23%
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 Tennessee surveyors wrote
F838 findings written in Tennessee, 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, isolatedApril 30, 2025
Based on facility policy review, observations, and interviews the facility failed to ensure the languages used by residents in the facility assessment was accurate to include sign language for 1 resident (Resident #12) of 17 residents reviewed.
The findings include:
Review of the facility's policy titled, Facility Assessment, dated 8/2024, revealed .a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations .and emergencies .The facility assessment will at minimum address or include .the care required by the resident population .that consider the types of diseases, conditions .and other pertinent facts that are present within that population . …
C · No harm, potential for minimal, widespreadAugust 22, 2024
Based on facility documentation review and interview, the facility failed to complete the facility assessment to accurately reflect the needs and services provided by the facility, which had the potential to affect 90 of 90 residents.
The findings include:
Review of the Facility Assessment Tool dated 7/28/2024, revealed the facility did not include the staffing parameters for the secure unit and contingency staffing protocol in response to emergency and crisis situations. Further review revealed on 5/1/2024, the facility's laundry service had changed with new building modification plans to add an in-house laundry room which was not reflected in the facility's assessment. …
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