of F164 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F164 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D266.7%
E133.3%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F164 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F164 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedOctober 12, 2017
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY
Based on medical record review, review of personnel files, review of a facility self-reported incident (SRI), staff interviews, and review of facility policies on Social Networking and Abuse, Neglect, Exploitation & Misappropriation of Resident Property, the facility failed to ensure a cognitively impaired resident's rights to privacy and confidentiality were maintained by a facility staff member during provision of personal care. …
Based on observation (via video recording clips), clinical record and policy review, the facility did not always ensured personal privacy for residents. According to video recordings of events occurring in Resident #2's room on 3-11-17 and 3-12-17, staff left the door open when providing personal cares to the resident exposing his/her naked body. A reasonable person would feel degraded, embarrassed and ashamed if exposed during cares. Concerns were noted for one resident (Resident #2) in a sample of seven (7) residents selected for review. The facility reported a census of 36 residents.
Findings include:
According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. …
E · No harm, potential for more than minimal, patternFebruary 22, 2018
Based on observation, interview, and record review, the facility failed to prevent unauthorized access, use, or disclosure of protected health information (PHI), personally identifiable information (PII), or confidential medical information (CMI) when two certified nursing assistants (CNAs) improperly accessed residents' information. This failure resulted in the access, use, or disclosure of PHI, PII, or CMI for 791 residents.
Findings:
On 6/14/17, the California Department of Public Health received a report which indicated on 5/25/17, (a former employee), CNA A reported that CNA B acquired residents' PHI from a computer server at the facility. …
B · No harm, potential for minimal, patternNovember 17, 2017
Based on observation, interview, and facility policy review, the facility failed to protect residents' confidential information, when a box containing records of approximately 30 residents was found in a Central Supply room. This failure had the potential to cause unauthorized access to the private records of all residents in the facility.
Findings:
During the Environmental Tour of the facility on 11/15/17 at 8:50 a.m., a white box was observed on the top shelf in the Central Supply room. The box labeled B.O. Financial Records 2015 contained approximately 30 residents' records. …
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