of F659 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202542
Every F659 citation surveyors wrote nationally that year.
Facilities cited40
Distinct nursing homes with at least one F659 finding.
The harm level
How severely F659 is cited
2.5% 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
J21.2%
K10.6%
L—
Actual harm
G10.6%
H—
I—
No harm, potential for more than minimal
D12777.9%
E2616.0%
F63.7%
No harm, potential for minimal
A—
B—
C—
Every recorded F659 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F659 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, isolatedNovember 20, 2025
Based on interview and record review, the Facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for 1 of 1 resident (R2) in the sample of 1. This failure resulted in R2 being transported via EMS (Emergency Medical Services) for reinsertion of a trach after dislodgement after nursing staff on duty failed to attempt to reinsert the trach because they weren't properly trained and didn't feel comfortable/confident in doing so. R2 remains in the Intensive Care Unit following trach reinsertion. This has the potential to affect current and new admissions that require tracheostomy care. …
Based on interview, record review, and facility document and policy review, the facility failed to ensure only licensed qualified staff replaced a resident's indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Specifically, Certified Medication Aide (CMA) #2, under the direct supervision of Registered Nurse (RN) #1, attempted to replace Resident #26's indwelling urinary catheter. As a result, Resident #26 experienced pain, bleeding from the insertion site, and bloody urine with clots.Findings included: A facility policy titled, Catheter Care, with a copyright date of 2024, indicated, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy… …
D · No harm, potential for more than minimal, isolatedAugust 18, 2026
Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care for 1(Resident #1) of 3 residents reviewed for personal property in that : The facility failed to ensure Van Driver A, who was not trained to handle financial transactions for residents, was requested to accompany Resident #1 to the bank to obtain bank statements.This failure could place residents at risk of not having the right personnel to manage their services. …
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