Based on resident interviews, staff interviews, an Ombudsman interview, police interviews, medical record review, and policy review, the facility failed to provide a safe discharge for Resident #19. This resulted in Immediate Jeopardy on 04/10/25 when Resident #19 was placed at risk for potential serious life-threatening harm, injuries, negative health outcomes and/or death when the facility discharged Resident #19 without providing a safe discharge location or provisions for a wound treatment. This affected one (Resident #19) of three residents reviewed for discharge. The facility census was 69. On 04/23/25 at 1:07 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #200 were notified that Immediate Jeopardy began on 04/10/25 at 3:00 P.M. …
F624
Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F624 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F624 finding.
The harm level
How severely F624 is cited
9.8% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J206.0% | K10.3% | L— |
| Actual harm | G123.6% | H— | I— |
| No harm, potential for more than minimal | D28183.6% | E195.7% | F20.6% |
| No harm, potential for minimal | A— | B10.3% | C— |
In the surveyor’s words
What an F624 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 interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were prepared for a safe discharge from the facility when the following occurred: 1. On [DATE], facility staff discharged Resident 1, who required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility, without arrangements for home health services (a wide range of health care services that you can get in your home for an illness or injury), as ordered by the physician. 2. …
Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer/discharge from the facility for (1) of (30) sampled residents, (Resident #65). The findings included: For Resident #65 the facility staff failed to provide and document sufficient preparation and orientation was provided to the resident in the clinical record to ensure a safe and orderly transfer/discharge to a higher level of care on 2/4/25. …
Based on medical record review and staff interview it was determined that the facility failed to orient, prepare, and document a resident for facility-initiated transfers out of the facility. This was identified for 1 of 1 resident (Resident #2) reviewed for transfers during a complaint survey. The findings include: Resident #2' s closed medical record was reviewed on 12/27/21. A review of the medical record revealed that the resident was transferred to an acute care hospital on 6/2/2021 and 6/17/2021. …
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