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 Virginia. Pick another state for the same tag.
Against expectation — 2025
Virginia cites F838 less often than its own record predicts
Versus expected share0.60×
0.60 times the national share — cited less often here than elsewhere.
Share of Virginia citations0.15%
Of every deficiency written in Virginia in 2025, this is the portion that was F838.
Virginia0.15%
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 Virginia surveyors wrote
F838 findings written in Virginia, 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.
G · Actual harm, isolatedOctober 4, 2023
Based on resident interview, staff interview, and facility documentation review, the facility staff failed to update the facility assessment to assess the needs of its resident population, the required resources to provide the care and services the residents need resulting in expression of psychological harm by one resident (Resident #22) in the survey sample of 46 residents.
Findings included:
The facility failed to develop and implement a plan to provide care and services to include education, training, and competencies related to the care of residents diagnosed with Post-traumatic Stress Disorder (PTSD) resulting in one resident (Resident # 22) expressing psychological harm.
On 09/25/2023 at 11:50 a.m. …
F · No harm, potential for more than minimal, widespreadMarch 18, 2026
Based on staff interview and facility document review, the facility staff failed to review and revise the Facility Assessment with changes in the administrative team members.The findings include:Review of the Facility assessment on 5/13/2026 documented the name of the administrator prior to November 2025. The next administrator employed was not listed, and the current interim administrator, who started in February 2026, was not listed. The Current Director of Nursing was not listed, and she came in November 2025. The Medical Director listed had ended his contract with the facility on April 1, 2026. The date the assessment was updated or revised was August 27, 2025.[NAME] interview was conducted with the Executive Director on 5/13/2026 at 4:50 p.m. …
C · No harm, potential for minimal, widespreadNovember 16, 2023
Based on staff interview and facility document review the facility staff failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents.
The findings were:
The administrator provided the survey team a facility assessment (FA) on 11/15/23 and reported to the team coordinator that the document had not been taken through the facility's quality program yet.
On 11/16/23 at 12:27 p.m., a surveyor reviewed the FA and discussed with the administrator how the document did not have facility-specific information; the document looked to be the template of an assessment, not personalized. …
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