of F641 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,996
Every F641 citation surveyors wrote nationally that year.
Facilities cited1,930
Distinct nursing homes with at least one F641 finding.
The harm level
How severely F641 is cited
0.1% 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
J20.0%
K—
L—
Actual harm
G30.0%
H—
I—
No harm, potential for more than minimal
D6,14678.5%
E1,16014.8%
F140.2%
No harm, potential for minimal
A—
B4806.1%
C260.3%
Every recorded F641 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F641 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 21, 2025
Based on record review, staff interview and review of the facility policy titled Conducting and Accurate Resident Assessment, the facility failed to accurately assess and code behavior symptoms on the Minimum Data Set (MDS) for three residents (R) (R1, R4 and R10) from a sample of 14 residents.
On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents.
The facility's Administrator and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE], at 11:47 am. …
Based on observations, interviews, and facility document review, it was determined that the facility failed to accurately identify resident verbal, physical, or other self-directed behavior symptoms as potential indicators of mental instability for 1 (Resident #1) of 1 resident reviewed for significant change assessment.
The findings include:
A review of Resident #1 ' s Admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included unspecified mood disorder, chronic pain, morbid obesity, malaise, and treatment refusal. …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on record review, resident and staff interviews, the facility failed to accurately code current tobacco use on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accuracy of assessments (Resident #38).The findings included:Resident #38 was admitted to the facility on [DATE].Resident #38's care plan revised on 7/14/2026 had a focus area for utilizing a vape and cigarettes. Interventions included Resident #38 would adhere to the tobacco/smoking policies of the facility, the facility would conduct a smoking safety evaluation on admission and as needed, educate resident/responsible party (RP) on the facility's tobacco/smoking policies, ensure vape was charged, provide smoking apron if Resident #38 choose to smoke a cigarette and Resident #38 required supervision with… …
B · No harm, potential for minimal, patternSeptember 10, 2026
Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for nine of sixteen residents (Resident R4, R13, R19, R23, R38, R41, R46, R56, and R69).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? …
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Assure that each resident’s assessment is updated at least once every 3 months.
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