of F425 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F425 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
D2100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F425 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F425 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.
K · Immediate jeopardy, patternNovember 7, 2017
Based on observation, interview and record review, the facility failed to provide pharmaceutical services , including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs three (Residents #2, #3, and #4) of four residents reviewed for pharmacy services.
A. Resident #2 had orders for routine and sliding scale insulin, but did not have parameters that established when the physician should be notified of her blood sugar (BS) level or when Resident #2's insulin should be held due to low blood sugar. Resident #2 had multiple incidents during September and October 2017 during which she had either dangerously high or low blood sugar levels.
B. …
Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assured the accurate dispensing of a drug for 1 of 6 residents sampled (Resident #1) when the pharmacy incorrectly labeled a liquid medication. This failure led to significant medication errors including nine omitted doses of an anti-seizure medication, and the administration of nine doses of a medication not ordered for Resident #1; placing the resident at risk for less than optimal health. …
D · No harm, potential for more than minimal, isolatedJune 21, 2018
Based on interview and record review, the facility failed to create a CDR (controlled drug record for medication having a potential for abuse and dependence) for pain medication brought from outside the facility by a resident (Resident 1). In addition, the facility failed to ensure licensed nurses (LNs) documented the administration of controlled pain medication to a resident (Resident 1) on the CDR.
As a result, there was the potential for diversion (theft) of controlled medications due to inaccurate accounting and documentation.
Findings:
Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].
On 5/14/18, Resident 1's record was reviewed.
Resident 1's admission orders [REDACTED]. Give 1 capsule every 4 hours as needed for moderate to severe pain. …
C · No harm, potential for minimal, widespreadSeptember 20, 2017
Based on observation, interview, and record review, the facility failed to ensure an expired medication was disposed of.
This failure has the potential to affect all 93 residents residing in the facility.
The findings include:
The facility's Resident Census and Conditions of Residents dated September 18, 2017, shows there were 93 total residents in the facility.
On September 19, 2017 at 9:12 AM, there was a stock bottle of Sennosides that had an expiration date of June 2017. The open date on the bottle was July 3, 2017. This was found in E7 RN's (Registered Nurse) medication cart. There was magnesium oxide and folic acid that expired in August 2017 in E9's LPN (Licensed Practical Nurse) medication cart. …
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