Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
of F584 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,277
Every F584 citation surveyors wrote nationally that year.
Facilities cited2,053
Distinct nursing homes with at least one F584 finding.
The harm level
How severely F584 is cited
0.7% 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
J70.1%
K250.3%
L200.2%
Actual harm
G80.1%
H20.0%
I—
No harm, potential for more than minimal
D4,32845.6%
E4,68149.3%
F2082.2%
No harm, potential for minimal
A—
B1501.6%
C600.6%
Every recorded F584 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F584 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, isolatedJuly 1, 2026
Licensure Reference Number 175 NAC 12-007.04CiBased on observation, record review, and interview the facility failed to develop and implement a plan to maintain required safe temperatures in resident rooms to prevent heat-related injury for facility residents. This affected 1 of 3 sampled residents (Resident 1). The facility census was 58.The facility Administrator was notified on 07/01/2026 at 12:45 PM of an Immediate Jeopardy (IJ) which began on 07/01/2026. The IJ was removed on 07/01/2026, as confirmed by surveyor onsite verification. Findings are:Record review of the undated facility admission Agreement revealed that the facility shall provide room, board, linens, bedding, and nursing care to the resident. …
Based on observation, interview, and record review the facility failed to have effective window safety latches to prevent a resident (R1) with Dementia and at risk for elopement from opening her 3rd floor room window. This failure resulted in R1 exiting through her 3rd floor window. Subsequently, staff observed R1 face down on the ground from her room window. R1 was unresponsive, blood from her face and abdomen on the ground when emergency services arrived. Police records document a death investigation.Findings include:R1's admission date was 6/30/2026. …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 9 residents (Resident #49) reviewed for a safe and comfortable environment.The facility failed to provide Resident #49 with a sanitary and clean bed after a bowel movement on 09/08/2026. This failure could place residents at risk of decreased resident satisfaction with their environment and a lack of a homelike environment.The findings included:Record review of Resident #49's admission Record, dated 09/10/2026, revealed a [AGE] year-old female admitted on [DATE]. …
B · No harm, potential for minimal, patternAugust 21, 2026
Based on observation, interview, and facility documents review, the facility failed to maintain a home-like environment for one nonsampled resident (Resident 61) and in Rooms B and C. * The facility failed to ensure the air conditioner vent inside Resident 61's room was clean. In addition, the facility failed to ensure Resident 61's fan next to the resident's head of bed was secured. * The facility failed to ensure the paint was not peeling in Room B's ceiling and in the hallway outside Room C. …
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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