Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
of F841 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202536
Every F841 citation surveyors wrote nationally that year.
Facilities cited35
Distinct nursing homes with at least one F841 finding.
The harm level
How severely F841 is cited
15.5% 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
J54.3%
K32.6%
L43.4%
Actual harm
G32.6%
H32.6%
I—
No harm, potential for more than minimal
D2824.1%
E1714.7%
F4942.2%
No harm, potential for minimal
A—
B—
C43.4%
Every recorded F841 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F841 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, widespreadSeptember 30, 2025
Based on interview and record review, the facility did not ensure the medical director followed through on his responsibilities regarding the coordination of care and treatment the residents received in the facility. This has the likelihood to cause serious harm, injury, or impairment to all 85 residents currently residing in the facility.Medical Director (MD)-QQ was not aware of and did not ensure facility residents with wounds had care and treatment necessary to prevent and heal pressure and non-pressure injury wounds. Medical Director-QQ deferred all wound care and treatment to the facility's wound team and Wound MD (Medical Doctor). …
Based on interview and record review the facility failed to ensure that the medical director fulfilled her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility regarding the surveillance of, and development of policies that reflect current professional standards of practice to prevent the spread of potential COVID-19 infection, and coordinate care of residents. This deficient practice resulted in ineffective COVID-19 mitigation, death of a resident from COVID-19, and resident abuse with injury.
1. Per review of the facility documented COVID-19 outbreak line list revealed that 11 Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. …
D · No harm, potential for more than minimal, isolatedAugust 25, 2026
Based on record review and interview, the facility failed to ensure the medical director:a. participated in QAPI meetings as part of the QAPI committee;b. reviewed and approved facility polices that directly affected resident care; andc. participated in the developing, updating, and reviewing the facility assessment. The administrator identified 34 residents resided in the facility. Findings:An undated document titled [NAME] Manor Quality Assurance Committee QAPI Committee showed the medical director was to be included as a quality assurance and assessment and QAPI committee member.A policy titled Medical Director, dated 04/2008, read in part, 2. The Medical Director is a licensed physician in this state and is responsible for:. d. …
C · No harm, potential for minimal, widespreadFebruary 6, 2026
Based on review of the Medical Director agreement, facility records, and staff interview, it was determined that the facility failed to ensure that the Medical Director fulfilled his/her responsibilities to develop, review, and improve resident care policies.Findings include:Review of the Medical Director agreement revealed he/she is expected to guide, approve, and help oversee the development, implementation, and monitoring/evaluation of the facility's resident care policies and procedures in several areas.Review of facility's annual policy reviews dated 1/28/26, revealed no signature by the Medical Director.Interview with the Nursing Home Administrator on 2/6/26, at approximately 12:12 p.m. …
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