of F839 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202561
Every F839 citation surveyors wrote nationally that year.
Facilities cited61
Distinct nursing homes with at least one F839 finding.
The harm level
How severely F839 is cited
1.9% 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
J20.9%
K—
L20.9%
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D10549.3%
E5626.3%
F4219.7%
No harm, potential for minimal
A—
B—
C62.8%
Every recorded F839 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F839 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, isolatedDecember 1, 2025
Based on Complaint #2625762, employee file reviews, and facility staff interviews, and facility documentation, it was determined that the facility failed to employ Licensed Practical Nurses in accordance with Maryland State laws. This was found evident for 2 (LPN #8 and LPN #14) out of 4 employees reviewed for appropriate licensures during the survey.The facility continued to employ LPN # 8 and LPN # 14 after the initial identification of non-recognized licensure on 4/3/24 through 11/21/25. …
D · No harm, potential for more than minimal, isolatedSeptember 2, 2026
Based on a review of practitioner credentialing information, clinical records, controlled-substance prescribing records, and staff interviews, the facility failed to ensure that 1 of 2 advanced practice registered nurses (APRN #2) maintained the required registration to prescribe controlled substances while providing professional services to facility residents. The findings include: A review of credentialing information for professional staff providing services at the facility, including two (2) advanced practice registered nurses (APRNs), identified that 1 of 2 APRNs did not maintain an active federal Drug Enforcement Administration (DEA) Registration required to prescribe controlled substances. …
C · No harm, potential for minimal, widespreadMarch 28, 2025
Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 12 staff (Respiratory Therapy Director) reviewed for staff qualifications.
The facility failed to ensure the Respiratory Therapy Director, while working as a Respiratory Therapist, was licensed to practice as a respiratory therapist in the state of Texas from August 2021 to August 2024.
This failure could place residents at risk of not receiving care and services from staff who were properly licensed.
The findings included:
Record review of the Respiratory Therapy Director's personnel file revealed a license from the National Board for Respiratory Care. …
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