of F886 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F886 is cited
5.5% 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
J10.4%
K10.4%
L134.8%
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D7025.6%
E10438.1%
F7928.9%
No harm, potential for minimal
A—
B10.4%
C41.5%
Every recorded F886 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F886 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.
K · Immediate jeopardy, patternMay 4, 2023
Based on interview and record review the facility failed to implement their Coronavirus (Covid-19) testing policy to prevent or reduce the spread of Covid-19 on the third floor nursing unit. This failure affected 25 of 45 (R16, R18 - R36, and R38- R43) residents reviewed for outbreak testing, and prevention of the spread of Covid-19. This failure resulted in V55 (nursing aide) testing positive on 3.29.23 the facility failed to follow their policy and test the residents who received direct care from V55 (R16, R19 - R36). The failure resulted in R19- R21 testing positive 13 days later. R18 displaying signs and symptoms of Covid-19 on 4.6.23, the facility failed to immediately isolate and test R18 allowing R18 to go out to the dentist. …
Based on Centers for Medicare & Medicaid Services (CMS) guidance, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 in the month of July 2022, for 30 of 30 unvaccinated employees (Employees E13 through E42).
Findings include:
Review of Centers for Medicare and Medicaid Services (CMS) document QSO-20-38-NH Revised 3/10/22, indicated routine staff testing frequency for staff who are not up to date on their vaccinations should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing. …
D · No harm, potential for more than minimal, isolatedMay 10, 2023
Based on review of policy, staff vaccination logs, personnel scheduling records, and staff interview, it was determined that the facility failed to conduct COVID-19 testing for one of three unvaccinated staff reviewed (Licensed Nurse Employee E4).
Findings include:
Review of facility policy, COVID-19 Vaccine Policies and Procedures, last updated January 2022, revealed, Staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions to mitigate the transmission and spread of COVID-19, which includes: 2 Time per week COVID-19 testing (administered on-site at the start of your shift).
Review of the facility COVID-19 Staff Vaccination Status for Providers revealed licensed nurse Employee E4 was listed as not being vaccinated with no exemptions on file. …
C · No harm, potential for minimal, widespreadApril 12, 2023
Based on interview and record review, the facility did not document that testing was completed for staff or residents with signs or symptoms of COVID 19. This has the potential to affect all 50 residents.
This is evidenced by:
Facility policy for testing in part; Testing of Staff and Residents with COVID-19 Symptoms or Signs
Staff with symptoms or signs of COVID-19, regardless of vaccination status, must be tested as soon as possible and are expected to be restricted from the facility pending the results of COVID-19 testing. …
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