of F658 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,933
Every F658 citation surveyors wrote nationally that year.
Facilities cited1,703
Distinct nursing homes with at least one F658 finding.
The harm level
How severely F658 is cited
1.9% 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
J270.4%
K90.1%
L30.0%
Actual harm
G971.3%
H20.0%
I10.0%
No harm, potential for more than minimal
D5,54875.8%
E1,58621.7%
F400.5%
No harm, potential for minimal
A—
B70.1%
C20.0%
Every recorded F658 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F658 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 5, 2026
Based on clinical record review, and staff interview, the facility failed to ensure care and services were provided in accordance with professional standards of clinical practice for 1 of 3 residents reviewed receiving insulin therapy for diabetes mellitus, Resident ID #1. Specifically, the facility failed to ensure a complete and clinically appropriate insulin order was obtained, accurately transcribed, and safely administered, resulting in the resident receiving rapid-acting insulin during overnight hours without meal intake, causing severe hypoglycemia requiring emergent hospital transfer. …
Based on clinical record review and staff interviews, the facility failed to ensure that care and services provided to 1 of 2 residents related to anticoagulation therapy, Resident ID #1, were in accordance with accepted professional standards of practice. Specifically, multiple staff members failed to appropriately question, clarify, verify, and communicate concerns regarding Resident ID #1's unusually high Lovenox (an anticoagulant medication prescribed to prevent and treat harmful blood clots) dose despite multiple opportunities to identify and prevent the medication error. These failures resulted in Resident ID #1 receiving more than twice the appropriate dose of Lovenox on 13 occasions. …
E · No harm, potential for more than minimal, patternSeptember 11, 2026
Based on select facility policy, clinical record review, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and competencies for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for two of 19 residents reviewed (Resident 8 and Resident 6). …
B · No harm, potential for minimal, patternApril 27, 2026
Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, for one sampled resident (Resident #114) reviewed for death, , the facility failed to ensure the resident had a physician order for a Registered Nurse (RN) to pronounce death. The findings include: Resident #114's diagnoses included hemiplegia, type 2 diabetes mellitus, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #114 had moderately impaired cognition. The nurse's progress note dated [DATE] at 2:59 AM written by RN #3 identified Resident #114 was unresponsive, no spontaneous breathing observed and pupils were fixed and dilated. …
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.
Cited in the same inspection, not caused by one another.
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