of F505 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F505 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
D1100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F505 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F505 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, patternOctober 19, 2017
Based on interview and record review, the facility failed to promptly consult the Physician or Physician Assistant (PA) of laboratory results that fell outside of clinical reference ranges for 1 of 13 residents reviewed for laboratory services. (Resident #16)
The facility failed to ensure Resident #16's abnormal lab results received on [DATE] were reported to the Physician.
Resident #16 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #16 expired in the hospital on [DATE].
These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. …
Based on clinical record review and staff interview, the facility staff failed, for two of 25 residents in the survey sample (Residents # 4 and 10), to promptly notify the residents' attending physician of abnormal lab results, resulting in harm.
1. For Resident # 4, the facility staff failed to notify the resident's attending physician of a lab result that identified the resident as having a urinary tract infection [MEDICAL CONDITION], leading to a one month delay in treatment, which lead to the resident being hospitalized and intubated, which constituted harm.
2. For Resident # 10, the facility staff failed to notify the resident's attending physician of low blood sugar and the initiation of hypoglycemic measures.
The findings include:
1. …
D · No harm, potential for more than minimal, isolatedApril 26, 2018
Based on interview and record review, the facility failed to follow its policy by not ensuring critical laboratory values for one of three sampled residents (Resident A) was reported to the physician in a timely manner.
This deficient practice placed Resident A at risk for mismanagement of care and delay in treatment.
Findings:
A review of Resident A's Admission Records indicated the resident was admitted to the facility on (MONTH) 11, (YEAR). Resident A's [DIAGNOSES REDACTED].
A review of Resident A's physician's orders [REDACTED].
A review of Resident A's Laboratory Report indicated a BMP and CBC was obtained on (MONTH) 21, at 3:35 a.m. …
B · No harm, potential for minimal, patternJuly 11, 2016
Based on observation, interview and record review, it was determined that the facility failed to assure timely notification of lab results to a physician in order for appropriate action to be taken if indicated for Resident #2, 1 of 25 residents reviewed for laboratory services.
This deficient practice was evidenced by the following:
On 07/01/16 at 11:30 a.m. the surveyor reviewed the record of Resident #2. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].
The surveyor reviewed the July 2016 physician's orders [REDACTED].
Further review of the resident's record revealed CBC results from 05/25/16, 06/15/16 and 06/29/16. Each report had abnormal results. Each report had a notation indicating that the results were faxed to the MD. …
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