of F221 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F221 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
D1100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F221 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F221 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, isolatedNovember 19, 2017
Based on observations, record review and physician and staff interviews the facility failed to provide an environment free from restraints when a resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility.
Immediate Jeopardy began on 11/15/17 when Resident #1 had his head stuck in the left side rail at the head of his bed and had to be released from inside the side rail by fire rescue personnel. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. …
Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from physical restraints. This was true for 1 of 5 residents (#2) reviewed for restraints and resulted in psychosocial harm when Resident #2 experienced increased agitation and distress from being physically restrained. Findings include:
Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was receiving hospice services as part of her treatment in the facility.
Quarterly Minimum Data Set (MDS) assessments, dated 5/19/17 and 8/17/17, documented Resident #2 was severely cognitively impaired, dependent on 2 staff for all Activities of Daily Living (ADLs) and mobility, and required no physical restraints. …
D · No harm, potential for more than minimal, isolatedMarch 6, 2018
Based on observation, interview, and record review, the facility failed to follow its policy by not ensuring all four bed side rails were left in the up position for one of three sampled residents (Resident 2).
This deficient practice had the potential for Resident 2 to feel entrapped and restrained while in bed.
Findings:
During a tour of the facility, on (MONTH) 8, (YEAR), at 12:45 p.m., Resident 2 was observed lying on bed with the bed (bilateral upper and lower) side rails up. During a concurrent interview, Resident 2 stated, They think I'm going to fall, when asked why all four side rails were in the up position.
A review of Resident 2's Admission Records indicated the resident was admitted to the facility on (MONTH) 15, (YEAR). …
B · No harm, potential for minimal, patternSeptember 19, 2013
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure an accurate assessment of a physical restraint for one of 15 residents. (Resident #5)
The findings include:
Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), an annual with an assessment reference date (ARD) of 8/21/13, showed the resident unable to partake in the brief interview for mental status (BIMS), so the staff have assessed the resident with having both short and long term memory loss and needing extensive assistance with decision making.
On 9/17/13 at 2:00 p.m., Resident #5 was observed in her room, sitting in her wheelchair with a lap buddy on. …
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