of F558 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,202
Every F558 citation surveyors wrote nationally that year.
Facilities cited1,115
Distinct nursing homes with at least one F558 finding.
The harm level
How severely F558 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%
K—
L—
Actual harm
G190.4%
H—
I—
No harm, potential for more than minimal
D3,86379.6%
E93219.2%
F140.3%
No harm, potential for minimal
A—
B210.4%
C40.1%
Every recorded F558 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F558 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, isolatedAugust 24, 2023
Based on observation , interview and record review the facility failed to ensure the rights to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #1) reviewed for resident rights.
The facility failed to ensure Resident #1 had his communication device when he was temporarily transferred to another room. While in the room Resident#1 yelled for help, and Resident #1 was sexually assaulted.
An Immediate Jeopardy (IJ) situation was identified on 08/23/23. …
Based on observation, interview, and record review, the facility failed to ensure a call light was in reach and residents had a means to call for help for 1 of 3 (R11) residents reviewed for accommodation of needs in a sample of 31. This failure resulted in R11 unable to receive help. It also resulted in R11 feeling frightened, frustrated, embarrassed, helpless and disposed of.Findings include:1. R11's admission Record, not dated, documents that R11 was admitted on [DATE] with diagnosis of Multiple Sclerosis and Quadriplegia. R11's Care Plan, dated 7/1/2025, (R11) has Quadriplegia. He requires assist with all of his ADL's (Activities of daily living). It also documents 8/4/2025 (R11) have Multiple Sclerosis. He is dependent on all ADLs. …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 of 4 residents (Resident #59) reviewed for reasonable accommodation of needs. The facility failed to ensure Resident #59's call light was in a position accessible to the resident on 09/12/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. …
C · No harm, potential for minimal, widespreadApril 22, 2026
Based on observation, interview, resident record review, and review of resident council minutes, the facility failed to ensure a sufficient supply of washcloths and towels available for morning care and as needed. This affected one resident (Resident #26) with the potential to affect all residents residing at the facility.Findings include:Record review for Resident #26 revealed an admission date of 03/19/26 with diagnosis including myocardial infarction, muscle weakness, pressure ulcer of right buttocks stage three, and pressure ulcer left buttocks stage two. Review of the Modification of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and was occasionally incontinent of urine. …
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Assist a resident in gaining access to vision and hearing services.
Cited in the same inspection, not caused by one another.
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