Top Cited Deficiencies from Nursing Home Recertification Surveys

Posted on October 14, 2021 by Jonathan Lips

The information available from the CMS Quality, Certification and Oversight Reports (QCOR) database shows that the Minnesota Department of Health (MDH) completed 100 nursing facility recertification surveys during the federal fiscal year ending Sept. 30. There is some lag time in survey data entry, so the year-end total is likely slightly higher. Here's a sampling of the data:

Top Health Deficiencies

• F880 Infection Prevention & Control
• F677 ADL Care Provided for Dependent Residents
• F755 Pharmacy Services/Procedures/Pharmacist/Records
• F684 Quality of Care
• F812 Food Procurement, Store/Prepare/Serve Sanitary

Top Emergency Preparedness Deficiencies

• E 0041 Emergency Power
• E 0039 EP Testing Requirements
• E 0037 EP Training Program
• E 0004 Develop EP Plan, Review and Update Annually
• E 0035 Sharing Plan with Patients

Top Life Safety Deficiencies

• K 0353 Sprinkler System - Maintenance and Testing
• K 0712 Fire Drills
• K 0345 Fire Alarm System - Testing and Maintenance
• K 0914 Electrical Systems - Maintenance and Testing
• K 0761 Maintenance, Inspection and Testing - Doors

Please visit our Care Center Survey Issues webpage for a more detailed list of the most frequently-cited deficiencies, along with sample survey findings for these tags.