of F825 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025162
Every F825 citation surveyors wrote nationally that year.
Facilities cited156
Distinct nursing homes with at least one F825 finding.
The harm level
How severely F825 is cited
2.6% 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
J20.3%
K10.2%
L—
Actual harm
G111.9%
H10.2%
I—
No harm, potential for more than minimal
D49184.8%
E7012.1%
F30.5%
No harm, potential for minimal
A—
B—
C—
Every recorded F825 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F825 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 14, 2025
Based on record review, and staff, Medical Director, and Orthopedic Surgeon interviews, the facility failed to communicate to the therapy department an Occupational Therapy (OT) referral ordered by Resident #63's Orthopedic Surgeon for evaluation and treatment of the resident's right olecranon (tip of the elbow). On 12/13/24 the resident underwent an open reduction internal fixation (ORIF) surgical procedure (involves making an incision to realign the bone and then holding the pieces together with hardware like plates, screws, or rods). …
Based on observation, interview, and record review, the facility failed to ensure physician-ordered rehabilitation services were implemented and monitored for one (R1) of three residents reviewed for rehabilitation services in the sample list of five. This failure resulted in R1 not receiving ordered rehabilitation services from admission through the time of survey, placing R1 at risk for avoidable functional decline and causing R1 to express fear, anxiety and depression. Findings include:R1's census record documents R1 admitted to the facility on [DATE].R1's Medical Diagnosis list documents R1 was admitted to the facility following a left lower extremity fracture requiring surgery and has diagnoses including Cellulitis of the left lower limb, Type 2 Diabetes Mellitus, Morbid Obesity,… …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had a history of Parkinson's Disease (a slow, progressive brain disorder that affects movement and the nervous system) and contractures (a permanent or severe tightening of muscles, tendons, skin, or other soft tissues that causes joints to shorten and become stiff), received a rehabilitation screen (a quick, basic check by a therapist to see if a resident needs a full therapy evaluation to improve or restore muscle function and movement) when Resident 1 was readmitted to the facility on [DATE].This deficient practice resulted in Resident 1 not receiving a rehabilitation screen which prevented the therapy department from assessing Resident 1's range of motion needs and… …
B · No harm, potential for minimal, patternNovember 8, 2018
Based on observation, interview and medical record review it was determined that the facility failed to ensure that specialized rehabilitative services was provided to 1 resident with a prosthetic device out of a standard survey sample of 18 residents. (Resident identifier is #51.)
Findings include:
Interview on 11/5/18 at approximately 10:45 a.m. with Resident #51 revealed that Resident #51 has not been able to utilize their prosthetic leg for approximately 5-6 months. Resident #51 stated, I have been telling them (the staff) for months that my prosthetic leg does not fit right. I have not been able to use it at all, nobody tells me anything.
Observation on 11/5/18 at approximately 10:45 a.m. …
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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