of F635 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202560
Every F635 citation surveyors wrote nationally that year.
Facilities cited58
Distinct nursing homes with at least one F635 finding.
The harm level
How severely F635 is cited
7.8% 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
J83.5%
K52.2%
L—
Actual harm
G52.2%
H—
I—
No harm, potential for more than minimal
D20086.6%
E125.2%
F—
No harm, potential for minimal
A—
B10.4%
C—
Every recorded F635 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F635 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.
K · Immediate jeopardy, patternNovember 19, 2025
Based on interview and record review, the facility failed to accurately reconcile physician orders needed to provide necessary care and services on admission, once the facility identified an issue with the admission orders, they failed to review the rest of the discharge summary for other potential missed orders for 1 of 3 residents in the sample (Resident #1). All residents admitting or readmitting to the facility are at risk for serious injury or death as a result of noncompliance. …
Based on interview and record review, it was determined that the facility failed to have physician's orders at admission for a wound that resulted in hospitalization for 1 of 4 residents reviewed for wound care (Resident identifier is #3).Findings include:Review on 12/17/25 of Resident #3's medical record revealed he/she was admitted on [DATE].Review on 12/17/25 of Resident #3's Clinical Admission assessment, dated 11/5/25, revealed a puncture wound present on admission to the right groin.Review on 12/17/25 of Resident #3's Vascular Surgery Discharge summary dated [DATE], revealed discharge instructions for daily wound treatment to the right groin wound.Review on 12/17/25 of Resident #3's admission orders revealed no treatment orders for the right groin wound.Review on 12/17/25 of Resident… …
D · No harm, potential for more than minimal, isolatedSeptember 4, 2026
Based on record review and interview, the facility failed to obtain physician orders for the resident's immediate care at the time the resident was admitted for one of six residents (Resident #63) reviewed for admission orders in that:Resident #63 did not have orders on file for admission to the memory care (secure) unit at the facility upon her admission [DATE].This failure could place the residents at risk of not receiving necessary care that could result in worsening of conditions or declines in the resident's health.The findings include:Record review of Resident #63's's face sheet, dated 09/01/2026, revealed an [AGE] year-old female with an admission date of 07/03/2026. …
B · No harm, potential for minimal, patternFebruary 15, 2024
Based on observation, interview, facility document review, and facility P&P review, the facility failed to obtain the physician's order for an adaptive device for one nonsampled resident (Resident 9). This failure had the potential for Resident 9 to not receive the appropriate care and services in the facility.
Findings:
Review of the facility's P&P titled Physician Orders revised 12/2008 showed all orders for the medications, procedures, and devices shall be clearly documented in writing in the resident's medical record.
Medical record review for Resident 9 was initiated on 2/12/24. Resident 9 was readmitted to the facility on [DATE].
On 2/12/24 at 1148 hours, observation was conducted with CNA 4 who was assisting and feeding Resident 9. …
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