of F552 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025586
Every F552 citation surveyors wrote nationally that year.
Facilities cited560
Distinct nursing homes with at least one F552 finding.
The harm level
How severely F552 is cited
0.4% 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
J10.0%
K10.0%
L—
Actual harm
G70.3%
H—
I—
No harm, potential for more than minimal
D1,65982.4%
E32316.0%
F140.7%
No harm, potential for minimal
A—
B80.4%
C10.0%
Every recorded F552 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F552 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, isolatedApril 18, 2026
Based on observation, interview, and record review, the facility failed to coordinate, communicate, and document the change in diabetic treatment plan for a chronically ill resident who required a surrogate for decision making, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. Resident #1 and her representative were not informed of the risks associated with not receiving diabetic care and were not given the choice to make an informed decision on the treatment plan. …
Based on staff interview, clinical record review, facility document review, the facility staff failed to uphold a resident's right to refuse care and treatment causing harm and resulting in a hospitalization for one of 36 residents in the survey sample, Resident #42. The findings include:For Resident #42 (R42), the facility staff forced the procedure to obtain a urine sample by physically restraining and forcing the insertion of a catheter causing harm resulting in hospitalization. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on interview and document review, the facility failed to obtain and document informed consent, including an explanation of risks and benefits, for 2 of 5 residents (R15, R135 ) reviewed for unnecessary medications.
Findings Include:
R15's quarterly Minimum Data set (MDS) dated [DATE], identified R15 was cognitively intact, with diagnoses which included anxiety, depression and bi-polar (manic and depressive episodes) disease. R15's MDS also identified R15 received antipsychotic, antianxiety, antidepressant and opioid medications.
R15's care plan revised 7/29/26, identified R15 had alterations in behavior, mood concerns, and history of psychiatric hospitalizations. R15 had aftercare following joint replacement surgery. …
B · No harm, potential for minimal, patternMay 13, 2026
Based on clinical record review, grievance form review, and staff interview, it was determined that the facility failed to timely inform and update an interested family member regarding changes in condition, ongoing assessments, and changes in treatment for one of nine residents reviewed (Resident 1).Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of spinal stenosis (narrowing between the spaces between the spines, putting pressure on the nerves causing pain in arms and legs) and kidney disease. …
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Provide care or services that was trauma informed and/or culturally competent.
Cited in the same inspection, not caused by one another.
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