of F441 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F441 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
D866.7%
E433.3%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F441 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F441 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.
L · Immediate jeopardy, widespreadNovember 21, 2017
Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program that prevented resident exposure to norovirus in the facility. The facility failed to promptly implement county health department recommendations to identify and track the virus and to promptly and consistently implement control measures, sanitation,(and) facility practices to minimize the spread of virus.
These failures contributed to a norovirus outbreak that spread to four units of the facility and to residents and staff residing and working there. This created a situation of immediate jeopardy with the potential for serious resident harm.
I. …
Based on observation, policy review and staff interview, the facility did not maintain and implement an Infection Control Program designed to prevent the development and transmission of infection during an ARI (Acute Respiratory Infection) outbreak and ensure staff followed professional standards related to hand hygiene practices for 4 (R1, R8, R2 and R3) of 10 sampled residents observed receiving cares.
The facility's Infection Control program failed to prevent the spread of an ARI starting [DATE] when 4 residents (R12, R9, R1 and R14) of 11 sampled and supplemental sampled residents were identified with ARI. The facility failed to ensure staff with signs and symptoms of ARI did not return to work until being symptom free for 24 hours. …
D · No harm, potential for more than minimal, isolatedSeptember 28, 2018
Based on observations, interviews, and record review, the facility failed to practice proper infection control procedures for 2 out of four sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had orders to be on contact isolation precautions, however, the staff was not wearing the appropriate personal protective equipment (PPE). This deficient practice has the potential to lead to the spread of infection.
Findings:
a.The Admission Face Sheet indicates Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE], with the [DIAGNOSES REDACTED].
The admission Minimum Data Set (MDS)(an assessment and care plan screening tool) dated 7/12/17, indicates Resident 1 is cognitively impaired, makes poor decisions and requires cues/supervision. …
C · No harm, potential for minimal, widespreadNovember 8, 2017
Based on a review of facility records, policy review, and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment for its residents for the period beginning June 2017 to August 2017. The facility census was 205.
Finding include:
Review of the undated Infection Prevention Manual revealed the facility's infection prevention program should include: surveillance of infections; investigation of outbreaks; regular review of the policies and procedures of the program with updates in response to changes; staff education related to infection prevention; incorporation of infection prevention into the quality assurance process; and the utilization of an Infection Preventionist to carry out the daily functions of the infection prevention… …
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