F628 in Pennsylvania. Pick another state for the same tag.
Against expectation — 2025
Pennsylvania cites F628 more often than its own record predicts
Versus expected share1.61×
1.61 times the share F628 takes of citations nationally.
Share of Pennsylvania citations1.50%
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F628.
Pennsylvania1.50%
National0.93%
Share of all citations that were F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F628 findings written in Pennsylvania, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedOctober 2, 2025
Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a provider (physician or designee) was notified in a timely manner of a resident who left the facility against medical advice (AMA). In addition, the facility failed to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services for one of six sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. …
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]. …
B · No harm, potential for minimal, patternAugust 6, 2026
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization (Resident R9, R58, R62, and R98). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. …
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