According to CASPER Standard Survey data (3/17/24), over 25 thousand deficiencies have been cited thus far this fiscal year (FY), spanning 215 distinct F-tags. This article aims to scrutinize the primary deficiencies across five regulatory groups/facility departments and proposes strategies for their avoidance.

Food and Nutrition Services

F812 Food Procurement, Store/Prepare/Serve Sanitary continues to top the list in standard surveys, with a citation rate of 44%. This requirement emphasizes the acquisition of food from reputable sources and adherence to professional standards throughout storage, preparation, and serving processes.

Guidelines outlined in CMS’s LTC Survey Pathway for Kitchen/Food Service Observation (CMS-20055) delineate these requirements comprehensively:

      • Storage Temps
      • Food Storage
      • Food Preparation and Service
      • Dinnerware Sanitation and Storage
      • Equipment Safe/Clean
      • Unit Refrigerators

Regular utilization of CMS-20055 as a Quality Assurance (QA) audit tool can go a long way in precluding these citations. Consider sharing the tool with dietary staff for training purposes and delegate portions of ongoing monitoring to team members to involve them in identifying and correcting potential issues.

 Infection Control

Ranked second in frequency, F880, focusing on Infection Prevention and Control, has been observed in 42.4% of standard surveys. This requirement spans a broad spectrum of criteria and is often cited due to lapses in proper hand hygiene practices or non-compliance with isolation protocols.

The CMS’s LTC Survey Pathway for Infection Prevention, Control, and Immunizations (CMS-20054) serves as a guide for survey teams during inspections, addressing tags F880*-F887 across various subcategories:

      • General Standard Precautions*
      • Hand Hygiene*
      • PPE use Standard Precautions*
      • Transmission Based Precautions (TBP)*
      • IPCP Standards/Policies/Procedures*
      • Infection Surveillance*
      • Water Management*
      • Laundry Services*
      • Antibiotic Stewardship Program
      • Infection Preventionist
      • Resident Immunizations
      • Staff Education and Offering COVID-19 Immunization

Regular use of CMS-20054, both in pre-survey preparations and annual assessments, facilitates the evaluation of a facility’s infection control program for regulatory compliance. Additionally, specific sections of the audit form, such as hand hygiene and standard precautions, merit regular, ongoing scrutiny depending on initial findings or recommendations from the Quality Assurance and Performance Improvement (QAPI) team.

Pharmacy Services

F761 concerning the Labeling and Storage of Drugs and Biologicals, ranks third in prevalence, with a citation rate of 31.1% in standard surveys thus far this FY. While categorized under ‘Pharmacy Services,’ this deficiency commonly arises from nursing staff non-compliance with regulatory guidelines, including proper dating and disposal of multi-dose vials and maintenance of controlled medication records.

Employing CMS’s LTC Survey Pathway for Medication Storage and Labeling (CMS-20089) for routine monitoring, coupled with targeted staff re-education on identified deficiencies, provides a proactive approach to mitigate this frequently encountered issue.

Quality of Care

F689, addressing the maintenance of a Hazard-Free Environment and Supervision Devices, holds the fourth position in citation frequency, with deficiencies given in 26.4% of standard surveys this FY. This regulation, impacting multiple departments within a facility, encompasses various accident scenarios, including falls, wandering, and environmental hazards (water temps, equipment, chemicals/toxins, electrical, etc.).

Once again, CMS has a LTC Survey Pathway for this regulation, Accidents Critical Element Pathway (CMS-20127). By following these 4 key areas outlined in the SOM Appendix PP, risk of this deficiency can be minimized:

  1. Identifying hazard(s) and risk(s);
  2. Evaluating and analyzing hazard(s) and risk(s);
  3. Implementing interventions to reduce hazard(s) and risk(s); and
  4. Monitoring for effectiveness and modifying interventions when necessary.

Resident falls is the most common reason for this citation. The 4 areas listed above from the SOM, is similar to the 5 steps of the nursing process (Assessment, Diagnosis, Outcomes/Planning, Implementation, Evaluation) and should be used in prevention and/or minimizing risk of falls. Facilities are often cited due to failure to identify the root cause of a resident’s fall and communicate any care plan revisions to staff.

Resident Rights

Ranked ninth, F584, pertaining to the provision of a Safe, Clean, Comfortable, and Homelike Environment, has been cited in 17.1% of standard surveys. Despite its classification under Resident Rights, this deficiency predominantly implicates the environmental services department and entails assessments of resident comfort, cleanliness, and safety.

Probes for this regulation include:

      • Does the resident have any concerns with lighting, noise, temperature, or anything else that may affect their comfort?
      • Are resident care areas and equipment kept clean and in good repair?
      • Does the resident’s room appear cluttered and disorderly, with a lack of storage for clothing, belongings or personal care equipment?
      • Are areas of the facility used by residents designed or organized to ensure the resident can receive care and services safely, without risk of falling or injury, while maximizing resident independence?
      • Do window treatments, bed linens, towels, privacy curtains, etc., appear clean and in good condition?
      • How does facility staff ensure resident personal property is kept safe from loss or theft?

Embracing a Person-Centered Care approach, facilities should ensure residents’ living spaces reflect individual preferences for a homelike ambiance, with regular monitoring procedures in place and procedures for resident feedback aiding in identifying areas of non-compliance.

Preventing Citations

The CMS LTC Survey Pathways are integral components of the audit and QA processes. Additionally, involving multidisciplinary teams in monitoring efforts and fostering effective communication and staff education are pivotal in sustaining compliance and promoting quality care delivery. Proactive’s Survey Ready Toolkit provides step-by-step action planning to delegate survey preparation assignments by department. Make plans to join an upcoming session of the webinar series Deconstructing IJ and High Risk Tags or catch past immediate jeopardy risk sessions on elopement, or falls & accidents on-demand. You can also join the new spring series Survey Prep & Understanding Post Survey Elements. Contact Proactive to schedule a mock survey, for help with a plan of correction, or for survey preparedness nurse consulting services.





Angie Hamer, RN, RAC-CT
Clinical Consultant

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