Based on observation, interview and record review, the facility failed to provide protection from sexual abuse to one resident (Resident #2), by Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over Resident #2, who had documented developmental disabilities and moderate cognitive impairment, while pulling up his/her pants. On [DATE] at 9 A.M., Social Services said the resident reported he/she had been asleep and stated upon waking, Resident #1 was positioned over Resident #2 while touching himself/herself. Resident #2 reported Resident #1 ejaculated into Resident #1's mouth, causing him/her to cough, and stated that he/she attempted to push Resident #1 away. …
F600 · Abuse and neglect
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F600 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F600 finding.
The harm level
How severely F600 is cited
37.7% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1,09412.0% | K3223.5% | L470.5% |
| Actual harm | G1,91120.9% | H650.7% | I30.0% |
| No harm, potential for more than minimal | D5,03555.1% | E6457.1% | F160.2% |
| No harm, potential for minimal | A— | B— | C10.0% |
In the surveyor’s words
What an F600 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.
Based on observations, interviews, and record reviews, the facility failed to ensure each resident was free from abuse for 2 of 6 residents (Residents #1 and #3) reviewed for abuse. The facility failed to ensure Resident #1, who had cognitive impairment, was free from sexual abuse when Resident #3 inserted his finger into Resident #1's vagina on 8/28/26. The facility failed to ensure Resident #3 was free from physical abuse when LVN B hit Resident #3 on the top of his head on 8/28/26. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. …
Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident R4).Finding include: Review of facility policy Abuse Protection dated 7/1/26, indicated each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. …
Cedar Hill Healthcare and Rehabilitation Center · Pennsylvania
By state — 2025
Where F600 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Arizona5.36× · 110 citations
- Colorado3.60× · 84 citations
- Illinois2.32× · 406 citations
- Oklahoma1.78× · 58 citations
- Connecticut1.62× · 68 citations
- Mississippi1.43× · 39 citations
- New York1.34× · 96 citations
- Missouri1.24× · 122 citations
- North Carolina1.18× · 64 citations
- Oregon1.12× · 28 citations
- Texas1.08× · 271 citations
- Florida1.04× · 83 citations
Co-occurrence
Cited alongside F600
Of the 2025 surveys that cited F600, these tags appeared in the same inspection more often than chance would predict.
- F61017.9% of F600 surveys · 2.9× chance
Respond appropriately to all alleged violations.
- F6077.5% of F600 surveys · 2.8× chance
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- F8353.2% of F600 surveys · 2.7× chance
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- F60926.8% of F600 surveys · 2.6× chance
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F7421.1% of F600 surveys · 2.3× chance
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Cited in the same inspection, not caused by one another.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction