of F465 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F465 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
D—
E1100.0%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F465 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F465 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.
L · Immediate jeopardy, widespreadNovember 5, 2017
Based on observation, interview, and record review, the facility failed to provide a safe environment in five of five resident halls.
The facility failed to repair broken or missing outlet covers in 10 resident rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) among all five halls, even after a fire occurred in resident room 111 as a result of a broken outlet cover.
This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/3/2017. While the IJ was lowered on 11/5/2017, the facility remained out of compliance at a level of no actual harm but potential for more than minimal harm with a scope identified as widespread. …
Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment for 2 of 5 residents reviewed for environmental conditions. (Resident #1)
The facility did not prevent Resident #1 from becoming infected with bed bugs and pubic lice. Resident #1 complained for approximately a month of itching and discomfort. The resident was sent to the hospital for shortness of breath and was found infested with lice and bed bugs and bites with pustules. Resident #1's roommate, Resident #2, had casings of bed bugs found in his mattress.
This failure could place the 28 residents who resided on the West Hall at risk for skin issues, unsanitary environment, and discomfort. …
E · No harm, potential for more than minimal, patternJanuary 18, 2018
Based on observation, interview and record review, the facility failed to ensure sanitary and safe shower rooms to the residents due to the presence of the following:
a. A 20-inch x 15-inch wall panel with missing tiles was stained with molds in one of seven shower rooms (Station 2).
b. A 3-inch diameter hole was noted beside the shower knob in one of seven shower rooms (Station 2).
c. A rusted shampoo/soap dispenser hanging by the shower wall was in one of seven shower rooms (Station 3).
These deficient practices had the potential to increase the risk to worsen respiratory infections or allergies [REDACTED].
Findings:
On 11/3/2017 at 7:45 a.m., an unannounced complaint visit was made to the facility. …
B · No harm, potential for minimal, patternNovember 16, 2017
Based on observation and interview, the facility failed to maintain two of three medication refrigerators (Refrigerators A and B) free of ice buildup. This had the potential for the refrigerators not being kept functional.
Findings:
Each nurses' station was equipped with a medication refrigerator containing an inner freezer compartment. The refrigerators were used to store the residents' medications.
On 11/15/17 at 1112 hours, an inspection of the facility's medication storage rooms was conducted with the DSD. Refrigerator A's freezer compartment was observed with ice buildup along its top inner surface. Refrigerator B's freezer compartment was observed with ice buildup along its bottom inner surface. One ice pack was observed imbedded in Refrigerator B's ice buildup. …
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