of F698 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025811
Every F698 citation surveyors wrote nationally that year.
Facilities cited792
Distinct nursing homes with at least one F698 finding.
The harm level
How severely F698 is cited
1.6% 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
J200.6%
K40.1%
L—
Actual harm
G330.9%
H10.0%
I—
No harm, potential for more than minimal
D2,89682.3%
E55515.8%
F50.1%
No harm, potential for minimal
A—
B30.1%
C20.1%
Every recorded F698 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F698 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, isolatedApril 27, 2026
Based on observation, interview, and document review, the facility failed to ensure residents receiving dialysis services were provided appropriate care and services, including failure to establish and implement an effective communication system with the dialysis center, failure to monitor and assess vascular access sites, failure to implement Enhanced Barrier Precautions (EBP), failure to monitor fluid restrictions, assess vital signs per physician orders, and failure to ensure sterile technique and follow physician direction for central venous catheter (CVC) care, for 2 of 2 residents (R16, R12) reviewed for dialysis services. …
Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure a physician-ordered fluid restriction was implemented and monitored for three (3) of five (5) dialysis residents. Resident #12, #43, and #58. Findings Include:
Record review revealed that the facility does not have a policy and presented a statement on facility letterhead dated 06/17/26, that stated, (Proper name) nursing home does not have a policy specific to fluid restrictions on dialysis residents, signed by the Administrator.
Resident #12An observation and interview with Resident #12 on 6/16/26 at 8:30 AM revealed she was lying in bed. A 32-ounce water pitcher full of ice water was located on the bedside table. …
D · No harm, potential for more than minimal, isolatedSeptember 4, 2026
Based on observation, interview and record review the facility failed to ensure residents who required dialysis received care and services consistent with professional standards of practice for 2 of 6 sampled resident (#s 13 and 72) reviewed for dialysis and unnecessary medication. This placed residents at risk for adverse side effects due to lack of appropriate coordination of dialysis care and services. Findings include:
Resident 13 was admitted to the facility in 9/2025 with diagnoses including end-stage renal disease requiring dialysis.
1 a. …
B · No harm, potential for minimal, patternFebruary 19, 2026
Based on record review and staff interviews, the facility failed to maintain evidence of ongoing communication with the dialysis treatment center in the medical record for 1 of 2 residents reviewed for dialysis (Resident #65). The findings included:Resident #65 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter waste and water from the blood). Resident # 65 was discharged on 12/19/25.Resident #65 had a physician order dated 12/4/25 for hemodialysis on Tuesday, Thursday, and Saturday.A review of Resident #65's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. …
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.
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