of F561 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025416
Every F561 citation surveyors wrote nationally that year.
Facilities cited410
Distinct nursing homes with at least one F561 finding.
The harm level
How severely F561 is cited
1.1% 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
J40.2%
K30.2%
L—
Actual harm
G150.8%
H—
I—
No harm, potential for more than minimal
D1,59081.1%
E33016.8%
F80.4%
No harm, potential for minimal
A—
B90.5%
C10.1%
Every recorded F561 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F561 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 21, 2026
Based on interview and record review the facility failed to honor R907's documented advance directive and failed to ensure the resident's right to refuse resuscitative efforts. R907 signed a code status form on [DATE] selecting a do not resuscitate (DNR) choice. According to progress notes dated [DATE] at 5:26 AM, the resident was found unresponsive and without a pulse. The resident was subjected to unwanted CPR (chest compressions, intravenous fluids, epinephrine three times) from 5:26 am to 6:00 am until emergency medical services (EMS) stopped the code, despite previously expressing a desire to forgo resuscitative measures. …
Based on observation, interview, and record review, the facility failed to ensure residents were permitted to exercise their rights when the facility obtained consent from family members for the placement of wander-guard devices without establishing that the family members had legal authority to make decisions on behalf of 2 of 3 residents (Residents 1 and 6) reviewed for resident rights. This failure caused actual psychosocial harm to Resident 1 by significantly compromising the resident's psychosocial well-being, as evidenced by persistent emotional distress, including crying; repeated statements of feeling imprisoned, trapped, and desperate; and expressions of suicidal ideation when the resident was prevented from attending church. …
E · No harm, potential for more than minimal, patternAugust 28, 2026
Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Residents #9, #80, #38, and #85). The facility census was 87.
Review showed the facility did not have a policy pertaining to the frequency and provision of showers per residents' preferences.
1. Review of Resident #9's face sheet (gives basic profile information), showed the following:-admitted to the facility on [DATE];-Diagnoses included anxiety disorder, yeast infection of genital areas (fungal infection), urinary tract infection (UTI), dementia, reduced mobility, depression, Rheumatoid arthritis (long term disease where body's immune system mistakenly attacks the… …
B · No harm, potential for minimal, patternMarch 17, 2026
Based on observation and interviews for 2 of 3 residents (Resident #83 and Resident #102) reviewed for choices and 7 out 7 residents (Resident #12, Resident #37, Resident #52, Resident #67, Resident #70, Resident #75, and Resident #85) that attended the Resident Council meeting, the facility failed to ensure dining rooms were opened for meals. The findings include: 1.Resident #83 was admitted to the facility in March 2025 with diagnoses that included Type 2 diabetes, chronic kidney disease and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #83 had intact cognition and was independent with eating. …
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Cited in the same inspection, not caused by one another.
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