of F157 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F157 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
D4100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F157 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F157 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.
K · Immediate jeopardy, patternNovember 20, 2017
Based on observation, interview, and record review, the facility failed to consult with the resident's physician and resident's family member when there was a significant change in the resident's physical, mental, or psychosocial status, for five (R#6, R #11, R #13, R #8, and R #2) of 19 residents reviewed for physician/ family consultation issues:
-LVN B provided treatment to R #6's right heel and right medial great toe without consulting the physician to inform her/him of the new pressure ulcers or receiving treatment orders.
The facility's identification, description, and documentation of R #6's pressure ulcer did not match R #6's current pressure ulcer status. …
Based on record review and interviews, the facility failed to immediately notify a resident's physician when a significant change occurred for one of five residents, R1, for change in condition. R1 was harm when he reported breathing difficulty, had significantly increased blood pressure and heart rate, and requested to be sent to the emergency department, but facility's nurse did not notify his physician in a timely manner and R1 died at the facility.
The findings include:
R1's medical record was reviewed. R1 was admitted to the facility for long term care with [DIAGNOSES REDACTED]. R1 had [DEVICE] ([DEVICE]) (tube placed in the stomach for feeding and medication) due to high risk of aspiration. …
D · No harm, potential for more than minimal, isolatedSeptember 14, 2018
Based on interview and record review, the facility failed to follow its policy titled, Incident Management, for one of three sampled residents (Resident 1). Staff failed to notify the physician of Resident 1's fall.
This deficient practice resulted in a delay of care. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 6/20/17 and diagnosed with [REDACTED].
Findings:
A review of Resident 1's Admission Record (face sheet) indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. …
B · No harm, potential for minimal, patternNovember 21, 2017
Based on a review of clinical records and staff interview, it was determined that the facility failed to notify a resident's responsible party of the need to initiate new treatment for one resident out of 11 sampled (Resident CR1).
Findings included:
A review of the clinical record revealed that Resident CR1 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED].
A review of a 14-day Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) completed during a previous facility admitted d (MONTH) 3, (YEAR), revealed that Resident CR1 was severely cognitively impaired. …
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