of F609 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,651
Every F609 citation surveyors wrote nationally that year.
Facilities cited2,296
Distinct nursing homes with at least one F609 finding.
The harm level
How severely F609 is cited
2.7% 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
J1491.6%
K520.6%
L120.1%
Actual harm
G390.4%
H30.0%
I—
No harm, potential for more than minimal
D8,09886.9%
E9069.7%
F450.5%
No harm, potential for minimal
A—
B100.1%
C30.0%
Every recorded F609 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F609 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 12, 2026
Based on observations, interviews, and record review, the facility failed to ensure allegations of abuse are reported immediately, but no later than two hours after the allegation is made, to the administrator of the facility and the New York State Department of Health in accordance with State law for three of three incidents of alleged abuse involving Residents #11, #63, and #90. Specifically, on 07/08/2026, Resident #90 filed a grievance stating Certified Nurse Aide #5 was rough with care and on 07/22/2026, during a Resident Council meeting, Resident's #11 and #63 reported Certified Nurse Aide #5 was rough with care. …
Based on Observation, Interview and Record Review, the facility failed to recognize and immediately report multiple allegations of staff to resident verbal and mental abuse to the facility's Abuse Coordinator and the State Agency for four of six residents (R1, R4, R5, R6) reviewed for Abuse in the sample of six. This failure resulted in multiple allegations of staff to resident mental and verbal abuse going unreported and left R4, R5 and R6 feeling mentally and physically upset and in fear of retaliation for reporting allegations themselves.Findings include:The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents policy, dated 10/1/23, documents It is the policy of the facility to empower and enable any and all owners, operators, employees, agents or contractors of… …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 9 residents (Resident #17) reviewed for abuse. …
B · No harm, potential for minimal, patternNovember 18, 2025
Based on interview and record review, facility staff failed to report investigative findings for reportable events, within the required timeframe, for 2 (#s 16 and 123) of 2 residents sampled for injuries. Findings include:1. Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigative findings were not reported to the State Survey Agency until 9/9/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he was responsible for submitting the facility's reportable incidents through the incident reporting system. …
Protect each resident from the wrongful use of the resident's belongings or money.
Cited in the same inspection, not caused by one another.
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