of F369 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F369 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 F369 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F369 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.
G · Actual harm, isolatedMay 10, 2012
Based on observation, review of the clinical record, staff interviews and review of an investigative report and an Event report submitted to the State Survey Agency, it was determined that the facility failed to consistently provide adaptive eating/drinking equipment as prescribed for one of 24 residents sampled (Resident 17).
The Findings include:
A review of the clinical record of Resident 17 revealed that the resident had [DIAGNOSES REDACTED]. It develops gradually, often starting with a barely noticeable tremor in just one hand). …
D · No harm, potential for more than minimal, isolatedNovember 17, 2017
Based on observation, interview and record review the facility failed to offer and provide assistive devices during meal services for 1 of 17 residents (R10) reviewed for assistive devices in the sample of 17.
Findings Include:
R10's admission Minimum Data Set (MDS), dated [DATE], documents R10 was admitted on [DATE] with the [DIAGNOSES REDACTED]. R10's most current MDS, dated [DATE], documents section G. Functional Status. H. Eating- how resident eats and drinks, regardless of skill is coded 3 for self-performance (resident involved in activity.) Support is coded 2 (one person physical assist.)
During lunch service on 11/14/17 at 12:16 PM, R10 was seated at the dining room table being fed by E4, Certified Nursing Assistant (CNA). …
C · No harm, potential for minimal, widespreadJune 19, 2014
Based on observation, interview and record review, the facility failed to provide one of 15 sampled residents (4) and one random resident (17) with devices designed to assist them with eating their food or drinking their beverages. This failure had the potential to cause residents who could feed themselves when using the devices, to require more assistance from staff.
Findings:
On 6/17/14 starting at 12 p.m. during trayline observations, Resident 4's tray card indicated he was to have a weighted cup. A review of his tray just before it was delivered to the unit, revealed it did not have any weighted cups on it.
During a concurrent interview, Cook 1 stated a Certified Nursing Assistant had told her the resident did not need to have a weighted cup anymore. …
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