of F637 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025260
Every F637 citation surveyors wrote nationally that year.
Facilities cited258
Distinct nursing homes with at least one F637 finding.
The harm level
How severely F637 is cited
0.3% 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
J10.1%
K—
L—
Actual harm
G20.2%
H—
I—
No harm, potential for more than minimal
D1,01590.5%
E585.2%
F10.1%
No harm, potential for minimal
A—
B423.7%
C20.2%
Every recorded F637 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F637 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, isolatedFebruary 18, 2022
Based on facility policy review, review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to identify a severe weight loss and decline in 1 or more Activities of Daily Living (ADL) as a significant change in a resident's condition and failed to complete a significant change assessment after a severe weight loss for 1 Resident (#30) of 4 residents reviewed for assessments. …
This citation pertains to intake #MI00138565.
Based on interview and record review, the facility failed to, 1) ensure a complete and accurate nursing assessment was done after a significant change involving 1 resident (Resident #701), and 2) ensure the facility had a policy to follow for assessment regarding signs/symptoms of infection (not feeling well, increased temp, tiredness, nausea), resulting in hospitalization with a diagnosis of urinary tract infection (UTI) and sepsis (extensive infection), antibiotic given, and the likelihood for serious injury. …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on a review of Resident Assessments Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessments for one of three samples residents (Resident R41).Findings include: Review of Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated [DATE], indicated the significant change assessments (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. …
B · No harm, potential for minimal, patternJuly 1, 2026
Based on clinical record reviews, review of policy and staff interviews for 2 residents ( Residents #8 and #17) reviewed for Hospice, and 1 resident ( Resident # 113 ) reviewed for accidents, the facility failed to document the date of determination for each Significant Change in Status Assessment (SCSA) in the clinical record, thereby ensuring the Significant Change Minimum Data Set (MDS) assessments were completed within fourteen (14 ) day required time frame. The findings included:
2.A clinical record review identified Resident #17 elected the Medicare hospice benefit on 4/21/26.
A social worker progress note dated 4/21/26 at 2:38 PM documented that a referral was made to the facility hospice vendor and the resident was enrolled in routine hospice level of care on 4/21/26. …
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Cited in the same inspection, not caused by one another.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction