of F610 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,641
Every F610 citation surveyors wrote nationally that year.
Facilities cited1,458
Distinct nursing homes with at least one F610 finding.
The harm level
How severely F610 is cited
5.6% 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
J1672.8%
K801.3%
L250.4%
Actual harm
G510.9%
H90.2%
I—
No harm, potential for more than minimal
D4,77980.5%
E77613.1%
F440.7%
No harm, potential for minimal
A—
B30.1%
C20.0%
Every recorded F610 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F610 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 6, 2026
Based on observation, interview, and record review, the facility failed to ensure staff intervened to protect a resident when they were sexually abused by a visitor when the visitor was observed by the staff member fondling Resident B's breast The facility also failed to investigate and prevent further abuse as evidenced by the same visitor being later observed fondling Resident B's perineal area under her incontinence brief for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse. …
Based on review of facility policies, clinical records, hospital records, and staff interviews, the facility failed to recognize and thoroughly investigate an injury of unknown origin involving potential neglect and failed to report the results of the investigation to the State Survey agency for one of three residents reviewed (Resident 5) resulting in actual harm evidenced by significant urethral trauma.Findings include:Review of the facility's Abuse Policy, last reviewed February 9, 2026, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on interview and record review, the facility failed to ensure that alleged violations of abuse, neglect, and exploitation were thoroughly investigated, and the results of the investigation were reported to the State Survey Agency within five working days for 2of 9 residents (Resident #17 and Resident #58) reviewed for abuse, neglect, and exploitation. The facility failed to have evidence of an investigation into alleged abuse of Resident #17 by Resident #58 on 09/05/2026This deficient practice could place residents at risk of continued abuse.The findings included:1. Record review of Resident #17's admission Record, dated 09/09/2026, revealed a [AGE] year-old male admitted on [DATE]. …
B · No harm, potential for minimal, patternAugust 12, 2025
Based on interview, facility document review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for one of five sampled residents (Resident 1) as evidenced by: * The facility did not interview the other resident, Resident 3 who was mentioned on interview to have caused distress to Resident 1. This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022 showed all allegations are thoroughly investigated. …
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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