of F431 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F431 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
D7100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F431 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F431 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, patternAugust 3, 2017
Based on observations, record reviews, interview, and review of the facility policy and manufactures' specifications, the facility failed to follow a procedure to ensure that medication was stored at proper temperatures in accordance with manufacture specifications in 2 of 5 medication rooms on 2 of 5 units reviewed for medication storage. Medications were stored at a temperature below manufactures specifications on the Morningstar and Day Spring units.
It was determined on 7/31/17 at 4:50 PM that Immediate Jeopardy existed in the following areas starting 7/1/17 when the facility staff first identified and recorded the improper temperature controls with medication storage. …
Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure medications were properly labeled from the pharmacy to reflect physician's orders [REDACTED]. On 7/1/17 and 7/2/17 at 11:30 A.M. and 4:30 P.M., Nurse #3 administered Novolin N (long acting insulin) instead of the Physician ordered Novolog (short acting insulin) to Resident #1. Resident #1 received glucagon (treats low blood sugar) on the night shift (11:00 P.M., to 7:00 A.M.) on 7/2/17 and 7/3/17 and was transferred to the hospital for evaluation.
Findings include:
Resident #1 was admitted to the facility in August 2015, medical history included: Type 2 Diabetes, chronic kidney disease stage 3, macular degeneration and vascular dementia. …
D · No harm, potential for more than minimal, isolatedMay 9, 2018
Based on interview, and record review, the facility failed to ensure timely receipt of medication for 1 of 3 sampled residents, who was newly admitted to the facility.
As a result, Resident 1 was not provided with her preferred and prescribed pain medication and had to take alternate medications for pain.
Findings:
Resident 1 was admitted to the facility on [DATE] at 2:25 P.M., for care after a hip replacement, per the Face Sheet.
Resident 1 was interviewed by telephone on 7/27/17 at 9:36 A.M. Resident 1 stated she first requested something for pain on 7/20/17 at around 5 - 5:30 P.M. and she was provided Tylenol for her pain. Resident 1 said theTylenol helped, only a little, and she requested something else for pain at 11:30 P.M. …
C · No harm, potential for minimal, widespreadNovember 17, 2017
Based on observation, interview, and facility policy and procedure review, the facility failed to ensure medications were stored under proper temperature control. This failure had the potential for medications that had lost their effectiveness to be administered to the residents for a census of 91.
Findings:
During an Environmental Tour of the facility on 11/15/17 at 9 a.m, a small medication storage room located inside the Central Supply room was inspected. There was no evidence of thermometer and the temperature was not monitored.
In a concurrent interview with the Central Supply (CS) room staff, on 11/15/17 at 9 a.m., she confirmed the medication storage room's temperature was not monitored. …
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