Ftag of the Week – F838 Facility Assessment (Pt 2)

Welcome back to the CMSCG Blog and Part 2 of our Ftag of the Week regarding F838 Facility Assessment. Last week, in Part 1, we identified the basic components of the Facility Assessment and provided some gentle reminders that providers may indeed be due for a review of their Facility Assessment to ensure that it accurately reflects the services being provided in the facility, the resources necessary to provide those services, and accurately captures the staffing levels necessary to provide adequate care and services. In this post, we will be looking at some of the components of the Facility Assessment and how providers have been cited related to those elements.


Facilities are expected to take a competency-based approach in determining what skills and knowledge are necessary for their staff to provide care to their residents. This knowledge, per the Interpretive Guidance (IG), includes understanding the ethnic, cultural and/or religious factors that staff may need to understand to provide services, including to meet the individualized needs of the residents related to food preferences, activities and to meet psychosocial needs.  So how is this being cited? Here are a few examples:

  • Review of a facility’s Resident Matrix provided to surveyors identified multiple residents who required tube feedings. Surveyors reviewed the Facility Assessment and found that it did not include any information on how the facility would care for residents who were tube fed, including how the staff would develop competency skills necessary and train staff on this type of care. (S/S: E)
  • When a provider’s Facility Assessment was reviewed, it did not include a comprehensive evaluation of the facility’s training program or information describing how areas identified for training of new and existing staff would be completed (S/S: F)
  • A facility failed to update its Facility Assessment when it decided to use agency nurses for staffing. The lack of update prevented the facility from ensuring that all staff were educated annually and had competency evaluations since they were agency staff and not employees of the facility (S/S: F)


Sufficient staffing levels have become a major focus of the regulators, and the Facility Assessment is one of the tools that is being reviewed much more frequently to compare actual facility staffing levels to what has been determined as sufficient in the Facility Assessment. Surveyors are identifying staffing problems throughout survey, whether it is through resident interviews where a resident says there is no one to help him get to the bathroom or through observations such as when multiple residents are seated during a meal with food in front of them and no one assisting them with eating. Staffing concerns can also be identified through record review and then be compared against the Facility Assessment, as we can see from this actual citation:

  • Multiple residents had care plans documenting that they required increased supervision for various conditions – 15 minute checks for elopement behaviors, 1:1 monitoring for falls, standby assistance for transfers/ambulation due to falls, and another resident who required frequent safety checks due to falls. Surveyors reviewed the Facility Assessment and identified that the document did not include sufficient information to ensure that the supervision required for these residents was considered when the facility’s staffing needs were determined. (S/S: F). This facility was also cited at an Immediate Jeopardy level at F725 related to Sufficient Staffing, Immediate Jeopardy level at F600 for ensuring residents were free from abuse, and at an Immediate Jeopardy level at F689 for failure to provide necessary supervision which resulted in falls with injury, unsafe wandering into other residents’ rooms and elopement.


It is necessary to think about what is required from all departments when looking at the whole picture of what types of residents the facility is admitting. The IG provides an excellent example about the considerations that a facility would make if it decided to add bariatric services – did the facility identify the necessary staff competencies, staffing levels and the physical equipment needed to take care of that population before residents were admitted? Providers should think about all of the components required before admitting a resident to meet all of their needs, and if residents with new types of conditions or services needs are going to be admitted, the Facility Assessment should adequately reflect this information. Let’s look at some of the citations facilities have received related to improper (or lack of) resource identification in the Facility Assessment:

  • Surveyors reviewed a monthly activity calendar and found that there were no activities that had been programmed to meet the needs of the facility’s residents living with dementia. The Facility Assessment was reviewed and surveyors found that it did not include comprehensive information about what resources were needed to adequately care for these residents (S/S: F)
  • Review of the facility’s census on survey identified that there were multiple residents with documented psychiatric diagnoses, a resident diagnosed with an intellectual disability and multiple residents living with other behavioral health needs. The Facility Assessment did not identify that there were any residents who had behavioral health needs, the special treatments and care they would require, or identify the resources necessary to meet their specific needs. Additionally, the Facility Assessment did not include any information on resident characteristics, ethnic needs, cultural needs and religious affiliation. (S/S: F)

As you can see, the Facility Assessment has become a real tool for surveyors to review and see whether your facility has appropriately planned for its resident population. Ensure that yours is updated as required annually, but also when there are changes in the needs of your resident population that necessitate changes to your staff and resources.

CMS Compliance Group, Inc. Consulting Services Inquiry

Does your organization need assistance with its Facility Assessment, revamping its training program or other assistance? Contact CMS Compliance Group, Inc. to discuss our interdisciplinary compliance and quality improvement consulting services for skilled nursing providers by filling out the form below or calling 631.692.4422.

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