of F606 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202557
Every F606 citation surveyors wrote nationally that year.
Facilities cited57
Distinct nursing homes with at least one F606 finding.
The harm level
How severely F606 is cited
2.1% 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
J10.4%
K10.4%
L10.4%
Actual harm
G20.8%
H—
I—
No harm, potential for more than minimal
D11246.3%
E5422.3%
F3916.1%
No harm, potential for minimal
A—
B10.4%
C3112.8%
Every recorded F606 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F606 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.
L · Immediate jeopardy, widespreadFebruary 24, 2025
Based on interview and record review, the facility failed to protect nine out of 97 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) from sexual abuse and the potential to affect all residents in the facility when the facility knowingly employed Certified Nursing Assistant 1 (CNA 1) with a history of a criminal misdemeanor (an offense punishable under criminal law).
This failure led to nine residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) being sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. …
Based on medical record review, review of facility documentation and interview it was determined the facility failed to ensure a criminal background check was completed on an agency GNA (geriatric nursing assistant) which allowed a GNA (Staff #11) with a criminal background of assault and sexual assault to care for vulnerable residents. This was evident for 1 of 4 agency GNAs reviewed for criminal background checks during a complaint survey. Resident #5 alleged Staff #11 sexually abused him/her on 1/25/25. This resulted in psychosocial harm to Resident #5. The findings include:A review was conducted on Facility Reported Incident 302934 on 8/18/25 related to Resident #5's allegation of sexual abuse by Staff #11 on 1/25/25. …
D · No harm, potential for more than minimal, isolatedAugust 19, 2026
Based on interview and record review, the facility did not ensure they did not employ an individual with a disciplinary action against their professional license by a state licensure body for 1 staff (Licensed Practical Nurse (LPN)-Y) of 8 sampled staff. The facility did not complete a thorough pre-employment background check for LPN-Y who worked in the facility as a licensed nurse without a valid nursing license. Findings include: The facility's undated Abuse Prevention Program indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment .In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. …
C · No harm, potential for minimal, widespreadJune 8, 2026
Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure background checks through the State Nurse Aide registry were completed on 2 of 5 sampled employees. The facility census was 45 with a total sample size of 25. Findings are:A. Review of the facility policy titled Vulnerable Adult updated 10/19/22 revealed the facility supported zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property. All potential employees were to receive a background check and verification of certification status for nursing assistants. The facility would not employee or otherwise engage individuals who:-had been found guilty of abuse, neglect, exploitation. …
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