of F661 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202569
Every F661 citation surveyors wrote nationally that year.
Facilities cited68
Distinct nursing homes with at least one F661 finding.
The harm level
How severely F661 is cited
1.2% 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
J70.9%
K—
L—
Actual harm
G20.3%
H—
I—
No harm, potential for more than minimal
D68090.9%
E425.6%
F10.1%
No harm, potential for minimal
A—
B131.7%
C30.4%
Every recorded F661 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F661 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 8, 2025
Based on observation, interview and record review, the facility failed to ensure that when the facility anticipated discharge of one (Residents #1) of three residents reviewed, there was a discharge summary that included a recapitulation of the resident's stay.
The closed records for Residents #1 that were reviewed did not contain facility discharge summaries that included a recapitulation of the residents' stay, signature of FM S/RP/POA confirmation of aftercare services for a resident that was impaired cognitively on 03/31/2025.
An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. …
Based on interview and record review, the facility failed to complete a discharge summary with required information for wound care and possible wound infection for 1 of 1 sampled resident (# 17) reviewed for unsafe discharge. The facility's failure to provide instructions for the care of the wound and the possible wound infection in the discharge summary information caused the resident's wound to worsen at home resulting in re-admission to a hospital. Findings include:
Resident 17 was admitted to the facility in 5/2024 with diagnoses including hip fracture with surgical repair, heart failure, and a history of falling.
Resident 17's care plan dated 5/14/24 indicated the resident required frequent skin inspections. …
D · No harm, potential for more than minimal, isolatedMay 12, 2025
Based on interview and record review, the facility failed to ensure a resident received a discharge summary at the time of discharge for 1 of 3 residents reviewed for discharge. (Resident B)
Findings include:
A. The clinical record for Resident B was reviewed on 5/7/25 at 9:35 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 10/10/24.
During a Confidential Interview, Resident B was given Resident E's medical record at the time of discharge. She did not receive any of Resident B's medical or discharge information.
An interview was conducted with the Executive Director (ED) and the Director of Nursing (DON) on 5/7/25 at 2:22 p.m. …
B · No harm, potential for minimal, patternApril 17, 2025
Based on interview and record review, the facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident (Resident #38), in a review of one closed records. The facility census was 36.
Review of the facility's undated policy for discharge/transfer showed the following:
-Purpose of the policy was to provide safe departure from the facility and provide sufficient information for after care of the resident;
-Complete a discharge summary and post discharge plan of care form which included:
a. List of medications with instructions in simple terms;
b. Instructions for post discharge care and explain to the resident and/or representative;
c. …
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