of F518 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F518 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
D3100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F518 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F518 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, isolatedAugust 3, 2017
Based on interview and record review, it was determined the facility did not implement emergency procedures for 12 of 39 sample residents. Specifically, the Missing Resident Policy and Procedure was not implemented when residents left the facility and did not return. Resident 47 left the facility and did not return while experiencing delusions and appeared manic and resident 10 sustained a needle stick from used syringes that was reported to the licensed nursing staff. The licensed nursing staff did not act on the needle stick for six days. The deficient practice identified for resident 10 and 47 was found to have occurred at an Immediate Jeopardy level. …
Based on interviews and records reviewed, the Facility failed to develop and implement an effective emergency preparedness plan for resident elopement for 1 out of 3 sampled residents (Resident #1), and 5 non sampled residents, when Resident #1, who had cognitive impairment, eloped from the Facility, and was found approximately 2 miles from the Facility, outside exposed to temperatures between 30 to 37 degrees Fahrenheit, for approximately 90 minutes, and sustained abrasions to his/her right knee, pain in both hips, a body temperature of 96.2 degrees F, and fatigue. …
E · No harm, potential for more than minimal, patternNovember 22, 2017
Based on interview and record review, three of three facility staff did not know the emergency code for bomb threat and one of three facility staff did not know the code for missing person. This deficient practice may delay the staff emergency response time that could lead to possible harm to residents, visitors, and staff.
Findings:
On 11/22/17 at 6:45 a.m., during interview, certified nurse assistant (CNA 3) stated the facility does not have a code for bomb threat.
On 11/22/17 at 6:55 a.m., during interview, certified nurse assistant (CNA 4) stated the facility does not have a code for bomb threat. …
B · No harm, potential for minimal, patternNovember 9, 2017
Based on observation, interview and record review, the facility failed to follow their policy on disaster training by failing to ensure employees know how to obtain electrical power in case of a power outage. This failure has the potential to affect residents who reside on the second and third floor of the facility.
The findings include:
On 11/8/17 at 10:00 AM during environmental tour with E4 (Maintenance Director) and E5 (Housekeeping Director), this surveyor asked E6 (Licensed Practical Nurse) how to get electrical power when there is a power outage. E6, after thinking for 30 seconds, stated I don't know.
On 11/8/17 at 10:30 AM during environmental tour with E4 and E5, this surveyor asked E13 (Certified Nursing Assistant) how to get electrical power when there is a power outage. …
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