May Survey Review
24 Reviews
12.0 average numbers of deficiencies up from 10.5 in April
288 total tags!
1 Zero deficiency survey. Congratulations, Caritas Center, from the
South-Central Region
1 Non-compliant re-visits resulting in 4 tags including no G level
tags
13 surveys resulted in 23 State deficiencies cited in addition to
Federal deficiencies.
9 G+ level tags
2~F309:
2~F314:
1~F320:
3-F323:
1~328
Regional Demographics Reported:
 Western Region averaged 9.8 deficiencies with 4 surveys
reported
 Southeast Region averaged 15.0 deficiencies with 4 surveys
reported
 South Central Region averaged 8.3 deficiencies with 3 surveys
reported
 Northeast Region averaged 15.8 deficiencies with 6 surveys
reported
 North Central averaged 9.9 deficiencies with 7 surveys reported
Ownership Status Reported

Non-profits averaged 10.0 deficiencies per survey
 For-Profits averaged 12.7 deficiencies per survey
67%
16/24
F441 Infection Control
63%
15/24
F323 Free of Accident Hazards/Supervision/Devices
F371 Food Procure, Store/Prepare/Serve-Sanitary
54%
13/24
F329 Unnecessary Drugs
50%
12/24
F253 Housekeeping & Maintenance Services
46%
11/24
F279 Develop Comprehensive Care Plans
F280 Right to Participate in Planning Care-Revise Care Plan
F428 Drug Regimen Review
38%
9/24
F315 No catheter, Prevent UTI, Restore Bladder
33%
8/24
F431 Drug Records, Label/Store Drugs & Biologicals
29%
7/24
F314 Treatment/Svcs to Prevent/Heal Pressure Ulcers
F520 QAA Committee-Members/Meet Quarterly/Plans
25%
6/24
F241 Dignity & Respect of Individuality
F325 Nutrition
F465 Safe/Functional/Sanitary/Comfortable Environment
21%
5/24
F309 Provide Care/Services for Highest Well-Being
F353 Sufficient 24-hr Nursing Staff Per Care Plans
F364 Nutritive Value/Appear, Palatable/Prefer Temp
S600 Dietary Services
17%
4/24
F248 Activities Meet Interests/Needs of Each Res
F278 Assessment Accuracy/Coordination/Certified
S1364 Electrical Requirements
13%
3/24
F156 Notice of Rights, Rules, Services, Charges
F226 Develop/Implement Abuse/Neglect, Etc. Policies
F242 Self-Determination-Right to Make Choices
F274 Comprehensive Assess After Significant Change
F281 Professional Standards of Services
F311 Treatment/Services to Improve/Maintain ADLs
F312 ADL Care Provided for Dependent Residents
F318 Range in Motion
F356 Posted Nurse Staffing Information
F425 Pharmaceutical Svc-Accurate Procedures
F456 Essential Equipment, Safe Operating Condition
F463 Resident Call System
F464 Dining and Resident Activities
8%
2/24-17
F157 Notify of changes (Injury/Decline/Room, etc)
F164 Personal Privacy/Confidentiality of Records
F166 Grievance Resolution
F221 Physical Restraints
F225 Investigate/Report Allegations/Individuals
F244 Family Groups
F246 Reasonable Accommodation of Needs/Preferences
F250 Provision of Medically Related Social Services
F275 Comprehensive Assessment After Significant Change
F322 Naso-Gastric Tube Feeding
F328 Special Needs
F406 Provision of Services
F490 Administration
F514 Res Records-Complete/Accurate/Accessible
S1146 Laundry Service
S1173 Nursing Facility Support System
S1354 Heating, Ventilation & AC
4%
1/24
F155 Treatment Refusal
F159 Facility Management of Personal Funds
F160 Conveyance of Personal Funds Upon Death
F161 Surety Bond-Security of Personal Funds
F167 Right to Survey Results-Readily Accessible
F174 Telephone
F223 Abuse
F257 Comfortable & Safe Temperature Levels
F258 Maintenance of Comfortable Sound Levels
F272 Comprehensive Assessments
F273 Comprehensive Assessment 14 days after Admit
F276 Quarterly Assessment at Least Every 3 Months
F320 Social Interaction Pattern
F332 Medication Errors
F333 Residents Free of Significant Med Errors
F334 Influenza & Pneumococcal Immunization
F354 Waiver-RN 8 hours 7 days/week, full time DON
F363 Menus and Nutritional Adequacy
F366 Substitutes of Similar Nutritive Value
F468 Equipment Corridors Handrails
F497 Regular In-Service Education
F501 Medical Director
S770 Other Resident Services
S795 Infection Control
S950 Laundry Services
S970 Nursing Facility Support Systems
S1358 Plumbing & Piping Systems
S1360 Plumbing & Piping Systems
S3186 Administration of Selected Medications
S3248 Staff Qualifications Employee Records
May Reflections
I am including the 2014 year-to-date data through June 9th for your review. I will also include it
next month.
As most of you already know, the 2567s will no longer be provided after June 30th at the time of
the surveys, so data will be delayed. The stakeholders will receive a list of facilities surveyed on
a quarterly basis and the surveys will be viewable on the KDADS website. The reason provided
by KDADS was that providing the survey findings at the time of the exit is leading to confusion
because of the revisions and the IDR processes. Continuation of the survey reviews will continue
but there will be delays in those findings and reflections.
Also included in the memo from
KDADS was the announcement of realignment of the survey regions. Facilities will be notified by
the regional managers during June and starting July 1, facilities should communicate with the
regional manager based on the re-mapping.
The finding summary from the G tags are as follows:
F309:
NC: SS=G: Failed to provide the necessary care & svcs, including thorough assessment & reassessment after a change in
condition or to seek phys involvement following a change in condition for res with prior hx of pneumonia & changes in physical
condition
NC: SS=G: Failed to provide care & services to multiple residents for physician ordered interventions for a res with inflamed
hemorrhoids who experienced pain with fecal impaction; failed to manage pain for res on hospice services; failed to monitor &
provide individualized interventions for res who exhibited purging behaviors; failed to monitor bowel elimination & provide
intervention; failed to monitor extensive bruising
F314:
NE: SS=G: Failed to document, assess & put interventions in place for newly recognized PUs
NE: SS=G: Failed to develop & implement timely & effective interventions to promote healing of PU & res’ PU increased in size
F320
NC: SS-G: Failed to ensure psychosocial needs of res were met & res did not display a pattern of decreased social interaction
&/or increased withdrawal, anger or depressive behaviors or lead to behaviors of alcohol consumption
F323
NC: SS=J: Failed to ensure res who facility had assessed as an elopement risk had adequate supervision to prevent res from
leaving facility without staff supervision placing res in immediate jeopardy
SC: SS=G: Failed to provide adequate supervision to prevent a fall resulting in laceration to arm that required sutures; failed to
thoroughly investigate root cause of falls for multiple residents & failed to assess & investigate possible accident hazards as
cause of res’ large, frequent skin tears & bruises
NE: SS=G: Failed to provide adequate supervision & timely interventions to prevent accidents; failed to ensure environment
free of accident hazards
F328
NC: SS=G: Failed to ensure multiple residents received proper treatment & care for tracheostomy & respiratory serves to
prevent URI
F441 was the number 1 tag cited in May and was cited in 67% of the surveys. I will be presenting a full
day training session at KHCA on July 9th. We will be teaching based on the survey findings with some
practical training with tools and procedures. If you are a LICA-MedMan subscriber, you can attend the
training for the cost that KHCA members pay. For non-KHCA, LICA-MedMan subscribers, do not register
on the KHCA website, but rather, call the KHCA office to register and please identify yourself as a LICA
subscriber.
Please share the thanks and the gratitude of the LICA-MedMan staff to your direct care partners since
their “day” is coming up. They are the heart and soul of every facility!
Have a great month! As always, if you have any questions or comments, please let me know. I’m happy
to help in any way possible.
Linda Farrar, RN/BSN/LNHA
linda@licamedman.com
785-383-3826