Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
of F837 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202559
Every F837 citation surveyors wrote nationally that year.
Facilities cited57
Distinct nursing homes with at least one F837 finding.
The harm level
How severely F837 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
J62.1%
K72.4%
L165.5%
Actual harm
G31.0%
H10.3%
I10.3%
No harm, potential for more than minimal
D5318.2%
E5318.2%
F13847.4%
No harm, potential for minimal
A—
B10.3%
C124.1%
Every recorded F837 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F837 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.
L · Immediate jeopardy, widespreadJanuary 19, 2026
Based on record reviews and electronic mail correspondence (email), the governing body failed to assume responsibility for the protection of all 187 residents by failing to act in a timely manner in regard to the failing fire suppression system.The findings include:A tour of the facility was conducted on 1/12/2026 by the Life Safety surveyor at 12:00 PM. During this tour, the surveyor noted the automatic fire sprinkler system (AFSS) and fire pump were red tagged and had been since 5/5/2025, indicating that the fire suppression system would not function as expected in the event of a fire. As of this annual survey, the facility failed to make the repairs to the automatic fire sprinkler system. …
Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when:
1. Resident 1 was not assessed for risk for developing pressure injuries upon admission.
2. Physician was not notified to obtain treatment for Resident 1's left heel redness.
3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness.
4. …
F · No harm, potential for more than minimal, widespreadAugust 18, 2026
Based on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of 1 of 1 facility reviewed for governing body.The facility failed to ensure the Director of Operations, who was acting as the facility Administrator, had an active Texas Administrator license. The facility had not had a licensed administrator since 07/08/2026. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care. …
C · No harm, potential for minimal, widespreadJune 6, 2026
Based on interview, document review, policy review and review of the Guam Code Annotated (GCA), the facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. This failure had the potential to result in ineffective oversight and lack of accountability and to affect all the residents of the facility. Findings include: During an interview during entrance conference on 06/01/26 at 10:06 AM with the Director of Nursing (DON), the Administrative Officer (AO), and Medical Director, the DON confirmed she was the Acting Administrator and did not have an Administrator's licensed. …
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