of F520 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F520 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
D—
E1100.0%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F520 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F520 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 5, 2017
Based on review of facility Quality Improvement Committee documents, medical record review, and interview, the Quality Improvement Committee failed to identify and implement corrective measures to address medication administration errors for 10 residents (#1, #3, #4, #6, #7, #8, #9, #10, #11 and #24) of 15 residents reviewed. The Quality Improvement Committee failed to ensure systems were in place for residents to receive medications as ordered by the physician and to be free of significant medication errors. …
Based on observation, interview and record review, the facility failed to develop and implement appropriate plans of action to maintain correction of quality deficiencies related to resident care plans, provision of services to maintain well-being (including restorative services), care for residents with tube feedings, and prevention of urinary tract infections (UTIs).
Findings include:
The facility had a complaint survey completed on August 9, 2017 and were cited for failure to develop comprehensive care plans, failure to provide services to maintain resident well-being, failure to implement interventions to prevent complications (such as urinary tract infections) related to indwelling foley catheters, failure to provide appropriate treatment for [REDACTED]. …
F · No harm, potential for more than minimal, widespreadFebruary 5, 2018
Based on observation, interview, and record review, the facility failed to have an effective Quality Assessment and Assurance (QAA) program, when the QAA committee did not adequately address and implement plans of action to correct deficiencies, when:
1. The abuse program was not implemented.
2. The facility failed to adequately and consistently assess and evaluate the occurrence of repeated falls for root cause so as to implement resident specific care interventions, provide adequate supervision and safety, and ensure its Fall Prevention Program policy was followed to prevent witnessed and unwitnessed accidents/falls for six of 45 sampled residents (Residents 14, 18, 24, 34, 39, and 41).
3. …
C · No harm, potential for minimal, widespreadOctober 27, 2017
Based on interview and record review, the facility failed to ensure the quality assurance process was followed by 1) lack of assuring care plans were developed and updates made on a timely basis for quality of care and residents with falls, and 2) lack of education of care staff about the quality assurance process in the facility which potentially effected all 50 residents in the facility. This deficient practice resulted in lack of timely care plan interventions and the potential for missed quality assurance issues. …
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