26 Reviews
9.3 average numbers of deficiencies down from 9.4 in January
234 total tags!
1 Zero deficiency survey. Congratulations go to Arkansas City
Presbyterian Manor (Southeast Region).
3 Non-compliant re-visits resulting in 22 tags including no G level tags
6 surveys resulted in 7 State deficiencies cited in addition to Federal deficiencies
10 G+ level tags
1~F225
1~F309
4~F314
1-F315
2-F323
1-F325
Regional Demographics Reported:
 Western Region averaged 9.3 deficiencies with 4 surveys reported
 Southeast Region averaged 5.4 deficiencies with 5 surveys reported
 South Central Region averaged 12.3 deficiencies with 2 surveys reported
 Northeast Region averaged 12.4 deficiencies with 7 surveys reported
 North Central averaged 7.9 deficiencies with 7 surveys reported
Ownership Status Reported
 Non-profits averaged 6.4 deficiencies per survey
 For-Profits averaged 12.8 deficiencies per survey
62% 16/26
F323 Free of Accident Hazards/Supervision/Devices
F441 Infection Control
50% 13/26
F329 Unnecessary Drugs
F253 Housekeeping & Maintenance Services

446% 12/26
F241 Dignity & Respect of Individuality
F371 Food Procure, Store/Prepare/Serve-Sanitary
42% 11/26
F428 Drug Regimen Review
39% 10/26
F314 Treatment/Svcs to Prevent/Heal Pressure Ulcers
35% 9/26
F279 Develop Comprehensive Care Plans
F431 Drug Records, Label/Store Drugs & Biologicals
31% 8/26
F309 Provide Care/Services for Highest Well-Being
27% 7/26
F280 Right to Participate in Planning Care-Revise Care Plan
F315 No catheter, Prevent UTI, Restore Bladder
23% 6/26
F225 Investigate/Report Allegations/Individuals
19% 5/26
F278 Assessment Accuracy/Coordination/Certified
F463 Resident Call System
F520 QAA Committee-Members/Meet Quarterly/Plans
15% 4/26
F272 Comprehensive Assessments
F312 ADL Care Provided for Dependent Residents
F353 Sufficient 24-hr Nursing Staff Per Care Plans
12% 3/26
F156 Notice of Rights, Rules, Services, Charges
F160 Conveyance of Personal Funds Upon Death
F242 Self-Determination-Right to Make Choices
F318 Range in Motion
F456 Essential Equipment, Safe Operating Condition
8% 2/26
F226 Develop/Implement Abuse/Neglect, Etc. Policies
F247 Right to Notice Before Room/Roommate Change
F257 Comfortable & Safe Temperature Levels
F281 Professional Standards of Services
F325 Nutrition
F327 Hydration
F354 Waiver-RN 8 hours 7 days/week, full time DON
F356 Posted Nurse Staffing Information

4%
F411 Dental Services
F412 Routine/Emergency Dental Services in NFS
F425 Pharmaceutical Svc-Accurate Procedures
F490 Administration
S600 Dietary Services
S1354 Heating, Ventilation & AC
1/26
F157 Notify of changes (Injury/Decline/Room, etc)
F159 Facility Management of Personal Funds
F161 Surety Bond-Security of Personal Funds
F174 Telephone
F244 Family Groups
F246 Reasonable Accommodation of Needs/Preferences
F252 Environment
F274 Comprehensive Assess After Significant Change
F311 Treatment/Services to Improve/Maintain ADLs
F332 Medication Errors
F362 Standard Sufficient Staff
F364 Nutritive Value/Appear, Palatable/Prefer Temp
F406 Provision of Services
F464 Dining and Resident Activities
F465 Safe/Functional/Sanitary/Comfortable Environment
F467 Adequate Outside Ventilation
F469 Maintains Effective Pest Control Program
F497 Regular In-Service Education
F503 Laboratory Services Cont.
F508 Provide/Obtain Radiology/Diagnostic Services
F518 Train All Staff-Emergency Procedures/Drills
S964 Nursing Facility Support System
S1166 Nursing Facility Support System
S1172 Nursing Facility Support System
February Reflections
For the reflections this month, the G+ tag findings will be included. Specific findings are found in the Finding Report. There were 2 “unusual” G+ tags this month that deserve some special attention as you review the report. It is seldom that Abuse/Neglect is tagged at such a high severity as an L and there was a G tag in incontinence this month with findings based on lack of following system procedures. As always, if you have any questions or comments please feel free to contact me. I am here to help!

F225-Abuse/Neglect Reporting
NE: SS=L: Failed to conduct a complete investigation & report allegations of abuse, neglect or exploitation for multiple residents including allegation that licensed nurse threw res to floor & incident not reported or thoroughly investigated & continued to work after allegation made which placed residents in immediate jeopardy and other incidents including possible exploitation
F309-Quality of Care
SE: SS=G: Failed to ID constipation & intervene in timely fashion to avoid fecal impaction; failed to notify physician of length of time of constipation, that interventions were ineffective, that res’ abdomen was firm & distended or that res experienced black tarry stool
F314-Pressure Ulcers
NE: SS=G: Failed to develop & implement interventions to prevent development of PUs for multiple residents
NC: SS=G: Failed to implement interventions to prevent development of a Stage IV full thickness tissue loss with exposed bone, tendon or muscle, often includes undermining & tunneling facility acquired PU
NC: SS=G: Failed to develop & implement interventions to prevent PU development in timely manner for res who developed 2
PUs on heels
SC: SS=G: Failed to consistently implement interventions to heal a current PU & prevent further PUs from developing for res with hx of PUs
F315-Catheters & Incontinence
SC: SS=G: Failed to assess a decline in urinary incontinence to determine causal factors & develop & consistently implement effective interventions in order to maintain as much normal bladder function as possible; res experienced decline in urinary status
F323-Accident Hazards
W: SS=K: Failed to ensure environment free of potential hazards when residents had access to hot water in excess of 140 degrees in DR, men’s BR & women’s BR hand-washing sinks; failed to provide adequate supervision (safe transfer) to prevent accidents; failed to ensure environment free of potential hazards when staff used toilet risers with unsafe, loose handrails
NE: SS=G: Failed to develop & implement timely & effective interventions to prevent falls & res with fall resulting in fx; failed to prevent res accessibility to hazardous chemicals
F325
NE: SS=G: Failed to develop & implement interventions to prevent & monitor weight loss resulting in significant weight loss
Linda Farrar, RN/BSN/LNHA linda@licamedman.com
785-383-3826