of F694 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025348
Every F694 citation surveyors wrote nationally that year.
Facilities cited342
Distinct nursing homes with at least one F694 finding.
The harm level
How severely F694 is cited
2.1% 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
J80.6%
K40.3%
L—
Actual harm
G141.1%
H—
I—
No harm, potential for more than minimal
D1,07185.0%
E15912.6%
F—
No harm, potential for minimal
A—
B40.3%
C—
Every recorded F694 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F694 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 27, 2026
Based on select facility policy review, clinical record review, review of Centers for Disease Control (CDC) guidelines, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate measures for the care and management of a midline peripheral venous access device (a vascular access tool inserted into an upper arm vein to serve as an alternative to a shorter IV for treatment) in accordance with facility policy and professional standards of practice for one of three residents (Resident 8). …
Based on medical record review, review of facility policy, review of informational articles from American Cancer Society, and interview the facility failed to develop and implement a system for identifying, monitoring, and caring for Resident #3's implanted venous access device (a port placed under the skin for use to administer intravenous treatments to mitigate risk for infection. This affected one resident (#3) of three residents reviewed for vascular access devices. The facility census was 102.Actual Harm occurred on 03/04/26 when Resident #3 was identified by a non-facility oncology nurse at an outside appointment to have a dressing to an implanted venous access device that was heavily soiled. …
E · No harm, potential for more than minimal, patternSeptember 11, 2026
Based on select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two of 19 residents reviewed (Residents 5 and Resident 6).Findings include: According to the Infusion Nurses Society (INS) (2024), Infusion Therapy Standards of Practice, the baseline circumference of an extremity with an intravenous catheter is measured upon insertion, noting location for future measurements to ensure consistent measurement. Facilities should assess circumference when edema or signs and symptoms of deep vein thrombosis (DVT) present, noting the location and characteristics of edema. …
B · No harm, potential for minimal, patternJune 25, 2025
Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access site for one of nonsampled residents (Resident 719) consistent with the professional standards of practice.
* The facility failed to ensure Resident 719's PIV was correctly labeled. This failure posed the risk for the resident to develop complications related to the IV therapy.
Findings:
Review of the facility's P&P titled Peripheral IV Catheter insertion revised 2/2022 showed placed label on one side of catheter (not over insertion site). …
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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