of F564 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20255
Every F564 citation surveyors wrote nationally that year.
Facilities cited5
Distinct nursing homes with at least one F564 finding.
The harm level
How severely F564 is cited
4.0% 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
G14.0%
H—
I—
No harm, potential for more than minimal
D1456.0%
E624.0%
F312.0%
No harm, potential for minimal
A—
B14.0%
C—
Every recorded F564 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F564 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.
G · Actual harm, isolatedJune 19, 2024
Based on observation, interviews, and record review, the facility did not ensure that residents had the right to receive visitors of their choosing at the time of their choosing for 1 of 19 residents (R5) reviewed for visitation rights. This resulted in R5 experiencing depression, financial hardship, and disinterest in participating in activities of daily living (ADLs).
R5's husband is limited by the facility to visiting between the hours of 8:00 AM to 4:30 PM, regardless of the resident's wishes. …
D · No harm, potential for more than minimal, isolatedMay 7, 2026
Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was provided the right to immediate access by family members, as required when the facility restricted Resident 1 from receiving visits and telephone communication from one of her daughters (DTR 3) and her son in law (SIL 1), based solely on another daughter's (DTR 1) designation as health care decision maker. The facility did not verify Resident 1's wishes, and there was no clinical, legal, or safety justification for restricting contact.This failure resulted in Resident 1 being denied communication and visitation with family members of her choosing, with the potential for psychosocial harm.A review of Resident 1's admission Record (facility demographic) indicated Resident… …
C · No harm, potential for minimal, widespreadFebruary 7, 2022
Based on interview, record review, review of Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-39-NH (revised 11/12/21), and review of a letter to family, the facility failed to inform residents and families of visitation rights. This had the potential to affect all residents. The facility census was 157.
Findings include:
Interview on 02/02/22 at 9:30 A.M. with Resident #110 revealed that a letter was sent out regarding visitation.
Review of the weekly letter regarding notification of positive staff or residents dated 11/25/21 and 12/17/21 revealed the letter indicated one new employee tested positive for COVID-19 and notice was provided of the case to the appropriate local, state, and federal authorities. …
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