Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for… …
F838 citations in Utah
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 — 2023
Utah cites F838 more often than its own record predicts
1.37 times the share F838 takes of citations nationally.
Of every deficiency written in Utah in 2023, 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 Utah surveyors wrote
F838 findings written in Utah, 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 did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings include: On 5/20/19 at 9:18 AM, the Facility Administrator (FA) was interviewed. The FA stated that he needed to get the facility assessment. The FA clarified that the facility assessment had not been completed due to needing to procure a program to complete it. …
What else Utah surveyors cite →
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