of F323 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F323 is cited
14.3% 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—
K114.3%
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D342.9%
E342.9%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F323 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F323 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, isolatedDecember 22, 2017
Based on observation, interview and record review, for one of four sampled residents (Resident 1) the facility failed to provide supervision to prevent accidents when:
1. Certified Nursing Assistant (CNA) 1 left Resident 1 unsupervised in front of the facility and Resident 1 eloped (left the facility's property without permission), and;
2. the facility did not monitor the functionality of Resident 1's individual WanderGuard (a system that tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area) device or the functionality of the WanderGuard door monitors (three of 12 door monitors did not sound an alarm). …
Based on staff interview, record review, and review of facility documents, the facility failed to ensure one of three sampled residents (Resident A) was transferred safely using a mechanical lift. This failure resulted in Resident A sustaining a left humeral (long bone of upper arm) fracture.
Findings:
Resident A was originally admitted to the facility in 2013 and [DIAGNOSES REDACTED]. Review of Resident A's Quarterly MDS (Minimum Data Set-an assessment tool), dated 7/20/17, described Resident A as having clear speech, usually able to understand others, able to make herself understood, long and short term memory problems, and severely impaired cognitive skills for daily decision making. …
D · No harm, potential for more than minimal, isolatedSeptember 28, 2018
Based on interview and record review, the facility failed to provide supervision to 1 of three sampled residents (Resident 1). Resident 1 was left unsupervised while sitting on the toilet in the bathroom. As a result, the resident fell from the chair. This deficient practice has the potential for further falls and injury.
Findings:
According to the Admission Face Sheet, Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. to perform every day activities).
The Resident Data Collection form dated 2/9/17 indicated, Resident 1 was confused and required assistance with transfers, ambulation and was bed bound.
A review of the Falls Risk Data Collection dated 2/9/17 indicated, Resident 1 was a high risk for falls with a score of 18. …
C · No harm, potential for minimal, widespreadNovember 9, 2017
Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for eight sample residents (Residents #1, #2, #3, #4, #5, #8, #10, and #11), out of 15 sampled residents, and two supplemental residents (Residents #19 and #20), with side rails, to ensure the environment remained free of accident hazards. The facility census was 74.
1. During an interview on 11/07/17 at 11:50 A.M., during the initial tour, Licensed Practical Nurse (LPN) A said Resident #11 uses 1/4 length side rails.
Observation on 11/07/17 at 3:30 P.M. showed the resident in his/her bed with one quarter-length (1/4) length side rail in the raised position.
Observation on 11/08/17 at 8:10 A.M. …
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