Based on observation, interview and document review, the facility failed to establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. This resulted in an immediate jeopardy (IJ) when R1 did not receive the necessary care and services for the treatment of pressure ulcers and pain management. R1's pressure ulcer went untreated for approximately six weeks and R1's pain was not controlled, limiting staff's ability to perform activities of daily living for R1. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met. …
F849
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F849 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F849 finding.
The harm level
How severely F849 is cited
0.5% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J50.4% | K10.1% | L— |
| Actual harm | G10.1% | H— | I— |
| No harm, potential for more than minimal | D1,13486.8% | E15011.5% | F80.6% |
| No harm, potential for minimal | A— | B40.3% | C40.3% |
In the surveyor’s words
What an F849 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.
Based on observation, record review, staff and family interview, the facility failed to establish a communication process between the nursing facility, the hospice provider, and the responsible party to ensure the resident needs are met for 1 resident (#1) of 3 residents reviewed who are currently receiving hospice services. Hospice is a specialized form of medical care that provides comfort and quality of life while facing a life limiting or terminal condition. Coordination of care between facility services and Hospice services is vital to ensure the highest level of comfort and care during the end of life. …
Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 6 residents (Resident #12, Resident #36, and Resident #32) reviewed for administration.1.The facility failed to maintain Resident #12's hospice binder with form 3074 (Texas Medicaid Physician Certification of Terminal Illness form. …
Based on interview, medical record review, and facility document review, the facility failed to ensure care was coordinated with the hospice provider for one of 12 sampled residents (Resident 8) reviewed for hospice. * The resident's hospice binder was not completed to show when the hospice provider visited Resident 8. This failure had the potential for the resident not receive the ordered hospice care services. Findings: Medical record review for Resident 8 was initiated on 10/2/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed physician's order dated 3/13/25, for hospice services to a hospice provider for diagnosis of terminal Cerebrovascular (CVA) Disease (a group of disorders that affect the blood vessels in the brain). …
By state — 2025
Where F849 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Kansas7.77× · 35 citations
- Pennsylvania1.84× · 33 citations
- California1.07× · 46 citations
- Texas1.03× · 27 citations
Co-occurrence
Cited alongside F849
Of the 2025 surveys that cited F849, these tags appeared in the same inspection more often than chance would predict.
- F75616.0% of F849 surveys · 4.9× chance
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- F69814.6% of F849 surveys · 4.7× chance
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- F75713.9% of F849 surveys · 4.2× chance
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- F60511.9% of F849 surveys · 4.1× chance
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- F88310.5% of F849 surveys · 4.0× chance
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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