of F699 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025357
Every F699 citation surveyors wrote nationally that year.
Facilities cited356
Distinct nursing homes with at least one F699 finding.
The harm level
How severely F699 is cited
1.8% 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
J20.2%
K10.1%
L—
Actual harm
G161.4%
H10.1%
I—
No harm, potential for more than minimal
D99488.4%
E1079.5%
F30.3%
No harm, potential for minimal
A—
B—
C10.1%
Every recorded F699 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F699 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.
K · Immediate jeopardy, patternNovember 1, 2024
Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 3 of 4 residents' (Resident's #2, #4, and #30) reviewed for trauma-informed care.
1. The facility failed to ensure Resident #30 was not held down and provided incontinent care while she was screaming and yelling stop, leave me alone on [DATE] by CNA K, CNA EE, Student NA FF, and Student NA O.
2. …
Based on review of facility policies, Resident Assessment Instrument (RAI) User's Manual, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization resulting in psychosocial harm for one of three residents (Resident R1).Findings include: Review of facility policy Trauma Informed Care dated 4/28/26, indicated the facility will provide individualized and personalized care to the residents. Understanding and adapting care to those with known trauma is an important part of the care provided. …
D · No harm, potential for more than minimal, isolatedSeptember 3, 2026
Based on clinical record review and staff and resident interviews, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood and behaviors (Resident 11).Findings include: Clinical record review for Resident 11 revealed the facility admitted him on June 5, 2026, with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). Review of Resident 11's history and physical dated May 8, 2026, revealed Resident 11's active problems included PTSD. …
C · No harm, potential for minimal, widespreadSeptember 25, 2024
Based on reviwe of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:21 PM, it was determined that the facility failed to ensure that trauma-survivor residents receive competent, trauma-informed care in accordance with professional standards and mitigate triggers that may re-traumatize the resident.
Findings include:
1. During the review of the procedure's manual, the policy and procedure with professional standards of trauma informed care practice.
The Compliance Officer (employee #2) was interviewed to see if they could find it in the manual, to which they indicated that it was not available, did they find any mitigation in the manual.
2. …
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Cited in the same inspection, not caused by one another.
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