of F156 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F156 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D—
E1100.0%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F156 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F156 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedFebruary 27, 2017
Based on interviews with staff and review of medical record and other pertinent documentation, the facility violated resident rights when the facility failed to obtain a written, signed admission agreement at or on admission, that ensured the resident and/or responsible party were aware of the rights, rules and regulations governing resident conduct and reposnsibilities during the stay; and then with no agreement in place, the facilty employed noncompliant systems for admissions, discharges and provision of care .
The implementation of these noncompliant facility systems resulted in all of the following. …
Based on interview, and record review, the facility failed to ensure each resident had the right to formulate an advance directive for code status for one of 11 residents (CR#1) reviewed for Advance Directives.
The facility failed to maintain a policy and procedure regarding Advance Directives and provide a copy of that policy and procedure to CR #1 or her responsible party upon admission.
This failure affected one resident and placed 113 residents at risk of not receiving prompt medical intervention in the event of an emergency, which could lead to a resident being resuscitated or allowed to die without intervention, against their wishes.
Findings include:
Intake # 4
CR#1
Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] at 12:00p.m. …
E · No harm, potential for more than minimal, patternJanuary 31, 2018
Based on record review, observation, and interview, the facility failed to ensure staff wore a name badge during their work shift to inform the residents who was caring for them.
This failure resulted in residents not knowing who was attending to their care.
Findings:
The facility policy and procedure titled Identification Badges, dated 11/07, indicates, It is the policy of this facility that all employees shall wear a name identification badge. In the procedure part of the policy, number 1 indicated All personnel are required to wear an identification tag or badge during their work shift.
During an observation and concurrent interview with certified nursing assistant (CNA 1), on 11/13/17, at 5 p.m., CNA 1 was observed not wearing a name badge. …
C · No harm, potential for minimal, widespreadNovember 27, 2017
Based on observation, group interview and staff interview the facility failed to have information about Medicaid and advocacy agencies easily accessible to residents. The facility reported a census of 59 residents.
Findings include:
During environmental tour on 11/27/17 at 12:30 p.m. observation revealed the local ombudsman contact information in the lobby of the front entrance but no Medicaid contact information. This lobby is located away from the 3 households that are located within the building. Each household has their own coded entry way with separate hallways to access the entrances. Each of the households did not have the information about Medicaid and advocacy contact information.
During group interview with 6 residents on 11/21/17 at 1:30 p.m. …
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