of F580 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,609
Every F580 citation surveyors wrote nationally that year.
Facilities cited1,449
Distinct nursing homes with at least one F580 finding.
The harm level
How severely F580 is cited
7.7% 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
J2123.4%
K731.2%
L20.0%
Actual harm
G1863.0%
H80.1%
I10.0%
No harm, potential for more than minimal
D5,33485.3%
E4096.5%
F60.1%
No harm, potential for minimal
A—
B170.3%
C30.0%
Every recorded F580 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F580 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 31, 2026
Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to notify and consult with a resident's physician regarding a significant change in condition for one of five sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of the facility policy entitled, Physician/Advanced Practice Provider (APP) Notification, dated [DATE], revealed that upon identification of a resident who has a change in condition, abnormal laboratory values, or abnormal diagnostics (tools used to identify, confirm, monitor, or rule out diseases and health conditions), a licensed nurse would perform… …
Based on observation, interview, and record review the facility failed to promptly notify the physician and resident's representative to obtain treatment for an acute change in condition for one of three residents (R1) reviewed for a change in condition in the sample of four. These failures resulted in R1 lying in excruciating pain for seven hours, and experiencing nausea, chills and anxiety resulting in R1's Family Member (V5) calling 911 to transport R1 to the hospital after staff refused to send R1 to the emergency room for treatment. …
D · No harm, potential for more than minimal, isolatedSeptember 23, 2026
Based on interview and document review, the facility failed to notify the physician for elevated blood sugar for 1 of 5 residents (R2) who was reviewed for unnecessary medications. Findings Include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, diabetes mellitus and arthritis. R2's MDS identified R2 required substantial maximal assistance with transfers, walking and dressing. R2 received insulin. R2's Care Plan dated 9/22/26, identified R2 had self-care deficit related to compression fracture, diabetes, Alzheimer's, dementia and chronic pain. Assist of one with grooming, dressing and bathing. Nails would be cut by nursing department. …
C · No harm, potential for minimal, widespreadDecember 19, 2025
Based on interview and record review, the facility failed to follow its room-to-room transfer policy for R1 by not notifying R1's power of attorney of a room change for one of three resident's review for transfers. Findings Include:On 12/18/25 at 11:27am, V3 (Social Service Director) said, we did not notify V11 (R1's Power of Attorney) for R1 room transfer on 9/16/25.R1 power of attorney paperwork dated 8/22/25 documents: V11. R1's electronic record did not document any notification on 9/16/25.Room to room transfer policy dated 4/2014 documents: Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer.
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.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Cited in the same inspection, not caused by one another.
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