Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment.The facility failed to ensure their Comprehensive Emergency Management Plan and Emergency Procedure Policy included adequate shelter to protect the elderly and at-risk resident population from the outdoor elements, such as extreme heat conditions. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.The findings included:During an interview on 8/23/26 at 3:35 p.m. …
F838 citations in Texas
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
Texas cites F838 less often than its own record predicts
0.33 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F838 findings written in Texas, 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 interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies and to review and update the assessment, as necessary, and at least annually for 1 of 1 facility reviewed for assessments. The facility failed to conduct and document a facility-wide assessment at least annually. This failure could place residents at risk for inadequate supervision, lack of resources and resident care to competently meet their needs.Findings included: Record review of the Facility Assessment, provided by the Administrator, revealed the assessment was dated 07/21/2025. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.62× |
| 2024 | 0.12% | 0.61× |
| 2025 | 0.08% | 0.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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