of F279 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F279 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
D888.9%
E111.1%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F279 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F279 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 staff interviews the facility failed to develop a comprehensive care plan which included side rails as a potential restraint for 1 of 1 sample residents reviewed for physical restraints. Resident #1's head was entrapped in the side rail of his bed and he had to be released from the side rail by fire rescue personnel (Resident #1).
Immediate Jeopardy began on 11/06/17 when the facility failed to develop a comprehensive care plan for the use of side rails for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. …
Based on interview, record review, and a review of the facility's policy and procedures, it was determined the facility failed to use the results of the resident's comprehensive assessment to develop a care plan for (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to require the assistance of two staff members for bathing and transferring. However, the facility failed to develop a care plan that reflected the resident's required assistance, and developed a care plan that stated that the resident only required the assistance of one staff member for bathing. On 08/13/17, State Registered Nurse Aide (SRNA) #1 assisted Resident #1 with transferring from the shower to a wheelchair, without the assistance of another staff member. …
D · No harm, potential for more than minimal, isolatedSeptember 14, 2018
Based on interview and record review, the facility failed to implement the plan of care for one of three sampled resident (Resident 1), who was assessed as high risk for falls.
This deficient practice resulted in a delay of care.
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].
A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 6/12/17, indicated a brief interview for mental status (BIMS) indicated Resident 1 was moderately impaired of cognitive (ability to think and reason) skills, had poor decision making, and required cues to remember. …
B · No harm, potential for minimal, patternSeptember 21, 2017
Based on observation, interview, and record review, the facility failed to ensure the comprehensive plan of care, for one of 20 sampled residents (Resident 3), was updated when Resident 3 refused to wear heel protectors when in bed as per physician's orders [REDACTED].>This failure had the potential to compromise the resident's skin integrity and develop skin breakdown.
Findings:
On September 19, 2017, at 5:50 p.m., Resident 3 was observed in bed with no heel protectors.
On September 19, 2017, at 6:32 p.m., Resident 3 was observed with Certified Nurse Assistant (CNA) 2 to not be wearing any heel protectors. In a concurrent interview with CNA 2, CNA 2 stated she had no heel protectors. CNA 2 further stated Resident 3 did not want to wear heel protectors.
Resident 3's record was reviewed. …
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