of F740 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025285
Every F740 citation surveyors wrote nationally that year.
Facilities cited274
Distinct nursing homes with at least one F740 finding.
The harm level
How severely F740 is cited
11.7% 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
J454.2%
K161.5%
L—
Actual harm
G605.6%
H50.5%
I—
No harm, potential for more than minimal
D83477.7%
E10810.1%
F30.3%
No harm, potential for minimal
A—
B—
C20.2%
Every recorded F740 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F740 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, isolatedAugust 20, 2026
Based on clinical record review, Medical Examiner records, staff interviews, first responder interviews, and policy review the facility failed to meet 1 of 3 resident's mental health needs (Resident #1), when they did not intervene per her care plan with her comments of wanting to die and did not update the provider of the ongoing comments. Resident #1 had diagnoses of depression, dementia with agitation, other symptoms/signs involving appearance and behavior, and altered mental status. The resident presented with a history of suicidal ideations, previous attempts while at the facility. The facility failed to notify the provider of the continued comments of wanting to die. …
Based on observation, interview and record review, the facility failed to provide the necessary behavioral services as recommended by the admission Preadmission Screening and Resident Review (PASRR, a federally required screening process used to check if a person applying to or living in a Medicaid-certified nursing facility has a serious mental illness, intellectual disability, or developmental disability) assessment for one resident and follow the behavior modification plan for Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over a sleeping resident with documented developmental disabilities and moderate cognitive impairment (Resident #2) and begged and pleaded for oral sex. …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on observation, interview, and document review the facility failed to ensure the behavioral health service provider was updated with symptoms and the need for a psychological visit for 1 of 1 resident (R151) reviewed for mood and behavior.Findings include:R151's quarterly minimum data set (MDS) dated [DATE], indicated R151 had impaired cognition, and was dependent on staff for most activities of daily living (ADL's). R151's diagnoses included major depressive disorder, dementia, multiple sclerosis, mood disturbance, and chronic pain.R151's care plan dated 8/25/26, indicated R151 had potential for mood concerns related to major depressive disorder, multiple sclerosis, chronic pain, and insomnia and had reported feeling down, depressed, and hopeless. …
C · No harm, potential for minimal, widespreadMay 2, 2023
Based on recertification survey review of policies and procedures, record review, and interview, with Medical Director (employee #3), it was determined that the facility failed to have an organized behavioral health care and services program, to promote the maintenance of highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to residents with mental and substance use disorders.
Findings include:
On survey procedures behavioral health care and services program policies and procedures were requested to the facility Medical Director. …
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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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