of F741 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202552
Every F741 citation surveyors wrote nationally that year.
Facilities cited49
Distinct nursing homes with at least one F741 finding.
The harm level
How severely F741 is cited
11.4% 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
J94.5%
K63.0%
L10.5%
Actual harm
G52.5%
H21.0%
I—
No harm, potential for more than minimal
D10049.8%
E6532.3%
F105.0%
No harm, potential for minimal
A—
B10.5%
C21.0%
Every recorded F741 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F741 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 7, 2025
Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, staff and family interviews, and facility policy review, the facility failed to recognize and address potential statements and behaviors that indicated Resident #1's self harm risk after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. …
This citation pertains to intake number MI00148293.
Based on interview and record review, the facility failed to ensure staff had appropriate competencies and skills needed to provide care in a manner that supported their psychosocial wellness in 1 (Resident #102) of 6 residents reviewed for behavioral competency, resulting in inappropriate staff to resident interactions, inability of staff to appropriately address the psychological distress, unmet care needs, and resident not maintaining or achieving highest practical psycho-social well being. …
D · No harm, potential for more than minimal, isolatedAugust 25, 2026
Based clinical record review, staff interview, and resident interview, the facility failed to ensure individualized interventions were implemented timely to meet the resident's behavioral health needs after a resident with a documented history of history of suicidal ideation expressed suicidal ideation on 8/11/26 to a facility staff member for 1 of 3 residents reviewed for behavioral health (Resident #3). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/22/26 revealed Resident #3 had diagnoses that included diabetes, anxiety, depression, post traumatic stress disorder(PTSD), and dissociative and conversion disorder. …
B · No harm, potential for minimal, patternDecember 22, 2023
Based on review of facility documentation, review of facility policy and interviews, the facility failed to have NA staff complete the annual competency course for dementia care. The findings include:
Review of NA #9's personnel file identified she has been employed at the facility since 3/30/22 on the 11pm to 7 am shift at 37.5 hours weekly. The file further identified a letter dated 7/6/23 that noted that NA #9 had not completed her yearly in-service trainings and that she would be removed from the schedule if the trainings were not completed. …
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