of F628 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,010
Every F628 citation surveyors wrote nationally that year.
Facilities cited989
Distinct nursing homes with at least one F628 finding.
The harm level
How severely F628 is cited
0.5% 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
J60.3%
K—
L—
Actual harm
G30.1%
H10.0%
I—
No harm, potential for more than minimal
D1,59973.8%
E38717.9%
F200.9%
No harm, potential for minimal
A—
B1024.7%
C482.2%
Every recorded F628 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F628 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, isolatedMay 20, 2026
Based on interview and record review the facility failed to follow their own discharge policy for discharging a resident for one resident (R5). This failure led to R5 being discharged to a home with no running water, with all of R5's medical supplies being left in the weather elements and being ruined, no food in the home and no home health assistance as ordered by the doctor. The failure of leaving R5's medical supplies on the porch has the potential for R5 to get infections in wounds that could lead to hospitalizations, serious illness or even death. The failure to have no home health set up for home could lead to multiple health concerns worsening and causing illness, hospitalizations and death. …
Based on interview and record review, the facility failed to document a resident's discharge correctly for 1 of 3 residents (R2) reviewed for discharge. This failure resulted in R2 losing his Medicare coverage from [DATE]-[DATE], having to cancel important diagnostic testing and a follow-up appointment with his neurosurgeon, not having CPAP (continuous positive airway pressure) supplies due to lack of medical coverage, and having to spend many hours and days trying to get his Medicare coverage reinstated.The findings include:R2's admission Record, printed by the facility on [DATE], showed he had diagnoses including, but not limited to partial intestinal obstruction, type II diabetes mellitus with hyperglycemia, gastrointestinal hemorrhage, anemia, acute kidney failure, neoplasm of… …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of four residents sampled with facility-initiated transfers (Resident R46).Findings include: Review of facility policy Documentation of Resident Discharge and Death dated 5/1/26, indicated documentation in medical record will be completed when a resident is discharged from this facility. Complete the resident transfer form. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. …
C · No harm, potential for minimal, widespreadAugust 15, 2026
Based on facility policy review, record review, and interview, the facility failed to ensure the state Ombudsman was notified of transfers and discharges, which affected 2 (Resident #6 and Resident #43) of 2 residents reviewed for hospitalizations and 1 (Resident #41) of 2 residents reviewed for change of condition.Findings included: A facility policy titled, Transfer and Discharge (including AMA [against medical advice]), dated 03/27/2026, indicated, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The policy revealed, 10. Emergency Transfers to Acute Care, which included h. …
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Ensure that residents are fully informed and understand their health status, care and treatments.
Cited in the same inspection, not caused by one another.
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