of F888 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F888 is cited
2.0% 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—
L20.8%
Actual harm
G31.2%
H—
I—
No harm, potential for more than minimal
D10742.5%
E4317.1%
F3915.5%
No harm, potential for minimal
A—
B20.8%
C5622.2%
Every recorded F888 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F888 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, widespreadOctober 12, 2022
Based on interview, record review and document review, it was determined that the facility failed to: a.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22; and, b.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. …
Based on interview, and record review, the facility failed to operationalize policies and procedures to ensure all staff were fully vaccinated for COVID-19 or possessed an approved exemption in a timely manner, in 2 of 20 staff members reviewed for COVID-19 vaccination status, resulting in the potential for transmission of COVID-19 to a vulnerable population.
Findings include:
Review of a COVID-19 Staff Vaccination Matrix, provided by the facility on 11/17/22, revealed Receptionist FF was highlighted in red (indicating exempt per the document key), with no COVID-19 vaccination information or exemption information documented on the form. …
D · No harm, potential for more than minimal, isolatedMay 18, 2023
Based on record review and interview, the facility failed to ensure one (housekeeper #1) of sixty-one staff members were fully vaccinated.
The Resident Census and Conditions of Residents report, dated 05/17/23, documented 46 residents.
Findings:
The COVID-19 Vaccine policy, dated 04/25/23, read in part, .COVID-19 Vaccinations and boosters will be offered to all Employee and Residents (or their representative if they cannot make healthcare decisions) per CDC and/or FDA Guidelines. Employees who refused to obtain the Vaccine and do NOT have an Exemption for Medical/Religious purposes will be considered Voluntary Resignation. …
C · No harm, potential for minimal, widespreadMay 23, 2023
Based on facility document review and staff interview, it was determined the facility staff failed to implement their COVID-19 vaccination policy to ensure staff were fully vaccinated, for one of eight staff members reviewed, OSM (other staff member) #15, housekeeper.
The findings include:
OSM #15 only had one dose of the Moderna (1) vaccine administered.
On 5/21/2023 at approximately 3:38 p.m., a request was made to RN (registered nurse) #1, the infection preventionist for a completed COVID-19 Staff Vaccination Matrix or a list containing the same information. …
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