For skilled nursing facility operators, the most common survey deficiencies might not be the ones always at the top-of-mind.

In multiple states, a Zimmet Healthcare Services Group (ZHSG) analysis found that food safety and procurement was the primary deficiency, among other areas, like basic infection control and resident rights.

“During interviews, the food quality often emerges as a complaint. However, it’s also about proper kitchen practices,” Amy Greer, Clinical Consultant, Quality Initiatives at ZHSG, said in a panel discussion at the firm’s recent “Roaring Reimbursement” conference in Connecticut. “Hazards, labeling, temperature control, and adherence to food safety guidelines matter.”

Greer and Alicia Cantinieri, VP of MDS Policy and Education at ZHSG, delved into the most common deficiencies in four different states: Connecticut, Massachusetts, Florida, and New Jersey.

While each state has its own set of concerns, there are certain recurring themes that resonate across geographical boundaries, Greer said.

One key takeaway for operators that emerges from these trends: Beware of tunnel vision on clinical elements in survey preparation.

“I think that when we’re preparing for a survey, there’s so much focus on the clinical aspect of it that we sometimes kind of forget the environmental aspects and the dietary aspects, the activities aspects,” Greer said. “It really has to be comprehensive with everything that you’re reviewing in your survey preparation.”

Breaking down the most common deficiencies

Five types of deficiencies emerged as common across the states that ZHSG analyzed, with food-related issues topping the list.

“The number one deficiency [in Florida and New Jersey] is ensuring procurement of food from satisfactory sources, as well as proper storage, preparation, distribution, and serving of food following professional standards,” Greer said.

This was also the fourth most common deficiency for SNFs in Connecticut and Massachusetts.

In addition to ensuring that the SNF is serving palatable food, surveyors will tour kitchens with an eye on safety issues. So, operators should review their practices related to whether food is being stored and served at the proper temperature, as well as how long food is being left out, Greer advised.

Greer said that another common deficiency, often noted as F-tag 880, pertains to implementing an infection prevention and control program, which encompasses basics like hand hygiene. Numerous citations result from improper hand washing, including during med passes and treatments. Neglecting this can lead to infection control and quality of care citations. 

Emerging issues related to inaccurate assessments also should be on operators’ radars.

““Thirteen percent of New Jersey facilities received citations for inaccurate assessments, highlighting issues with MDS coding and doctor assessments,” Greer said. “This trend seems to be growing across states.”

And medication errors exceeding 5% feature prominently as an area requiring heightened attention.

“In Florida, 14% of nursing homes receive citations for medication errors exceeding 5% or more,” Greer said.

Another common deficiency across all five states was Ensuring drugs and biologicals used in the facility are labeled in accordance with currently accepted professional

principles; and all drugs and biologicals must be stored in locked compartments for controlled drugs.

Even one “rogue blister pack” of a drug such as Percocet or Dilaudid can trigger a tag in this area, Greer said, so facilities must be strictly disciplined in making sure such meds are properly counted and secured.

Insulin is another focus for surveys.

“Make sure that when your staff is opening up a new vial of insulin that they’re putting the date it was opened, because, as we all know, you have 28 days and then you need to throw it away,” Greer said. “That is often one of the main reasons, when I see this cited, it’s going back to your insulin and your insulin pens.”

In Connecticut, the top deficiency — affecting 46% of SNFs — revolved around ensuring appropriate treatment and care in accordance with orders, resident preferences, and goals. Massachusetts received the most citations for a lack of robust care planning, particularly in the context of respiratory care.

In the Bay State, 29% of facilities received citations for not providing safe and appropriate respiratory care when required.

Resident rights

Resident rights is a big area of concern as well. Greer said operators want to make sure that their residents are being treated with dignity and respect, that they’re being involved in their care planning, that they’re being involved in their daily activities.

She added that residents have the right to refuse treatment, and that refusal should be documented. She said that empowering staff to bring issues to administration is also important.

“A lot of times, it’s your CNA that has that great idea,” she said. “And it can be one of the best ideas that you know, no one in administration even thought of.. The CNAs are the eyes and ears of your facility, and they really do know what’s going on with the residents.”

Still, operators said that sometimes despite their best efforts, citations feel inevitable.

Accolade CEO Moe Freedman described an instance where Accolade, a provider of skilled nursing care across six skilled nursing facilities in Central Illinois, received a citation for abuse, after a worker had stolen money from a resident. Freedman said the issue was handled promptly and properly – the employee was terminated and the money was returned to the resident.

Yet his facility still received a citation.

“We should all be here for the same reason that we understand why IDPH is there, and we need them there,” he said. “We need to have checks and balances, but it should be more collaborative than it is.”

His perspective is shared by Kimberly Green, COO of Diakonos Group, which operates eight skilled nursing and rehab centers, five intermediate care facilities and one assisted living community, all in Oklahoma.

Green is concerned about improper citations connected with the fact that many survey teams are inexperienced, with many surveyors recently hired due to recent high turnover among more seasoned surveyors. These “green” surveyors are entering facilities with a lot of passion to do their jobs, but “not necessarily understanding” the job yet, Green told SNN.

Such reports only reinforce the need for strong survey preparation, and knowledge of which deficiencies are most common should be able to help operators focus their efforts.