of F626 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202561
Every F626 citation surveyors wrote nationally that year.
Facilities cited61
Distinct nursing homes with at least one F626 finding.
The harm level
How severely F626 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
J51.5%
K—
L—
Actual harm
G144.1%
H—
I—
No harm, potential for more than minimal
D30489.9%
E144.1%
F10.3%
No harm, potential for minimal
A—
B—
C—
Every recorded F626 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F626 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, isolatedMarch 5, 2025
The facility reported a census of 100 residents with eight residents sampled and one resident reviewed for proper discharge from facility. The facility failed to readmit Resident (R) 77 back into the facility. The likelihood for a serious adverse outcome existed, due to the threat to R77's continuity of care, feelings of insecurity to his safety in not having a place to discharge to after the facility had been providing his care for the past two years and four months. The negative psychosocial impact is significant and traumatic, with R77s history of having to live in a men's shelter. …
Based on interview, clinical record review, and document review, the facility failed to ensure a resident was permitted to return to the facility following a visit to the hospital for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in an unsafe and unnecessary resident discharge, placing the resident at risk for physical and emotional harm
Findings include:
Resident #25
Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.
Resident #25's care plan dated 02/20/2025, documented Resident #25 had an impairment to the skin integrity of the resident's right foot related to a surgical wound. …
D · No harm, potential for more than minimal, isolatedApril 25, 2025
Based on record review and interviews, the facility failed permit a resident to return after a hospitalization or therapeutic leave for one (#212) of three residents out of 31 sample residents.
Specifically, the facility failed to reassess Resident #212's status at the time the resident sought to return to the facility after a transfer to the hospital, and did not allow the resident to return to the facility, based upon her status at the time of her transfer to the hospital.
Findings include:
I. Facility policy and procedure
The Facility Initiated Transfer or Discharge policy, revised October 2022, was provided by the nursing home administrator (NHA) on 4/10/25 at 2:51 p.m. …
B · No harm, potential for minimal, patternSeptember 27, 2018
Based on review of clinical records, the facility Discharge/Transfer Letter Policy and Bed Hold Notices provided to residents upon transfer from the facility and interview with facility staff revealed that the facility failed to demonstrate the implementation of specifically delineated procedures for Medicare payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language to one resident out of three reviewed (Resident CR1).
Findings include:
A review of Resident CR1's clinical record revealed that the resident was Medicare payor source and had been transferred to the hospital on (MONTH) 13, (YEAR), due to a change in clinical condition. …
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