of F895 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20259
Every F895 citation surveyors wrote nationally that year.
Facilities cited8
Distinct nursing homes with at least one F895 finding.
The harm level
How severely F895 is cited
0.0% 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
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D1123.9%
E1021.7%
F2247.8%
No harm, potential for minimal
A—
B—
C36.5%
Every recorded F895 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F895 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.
E · No harm, potential for more than minimal, patternJuly 31, 2026
Based on interview and document review, the facility failed to implement an effective compliance and ethics program with sufficient monitoring and auditing mechanisms to detect and prevent potential violations and ensure the integrity of the data reported to the Centers for Medicare and Medicaid services (CMS). The facility further failed to ensure employees could report, without fear of retaliation, a high-level personnel's suspected violations. These failures resulted in documentation and minimum data set (MDS) irregularities with unsupported or inconsistently reported diagnosis for 4 of 4 residents (R31, R39, R40, R61) reviewed. Findings include: R31's admission Record identified an admission date of 1/25/23. …
C · No harm, potential for minimal, widespreadFebruary 25, 2025
Based on interview and record review, the facility did not develop a compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and promote quality of care. This has the potential to affect all 43 residents.
Findings include:
On 02/25/25, Surveyor reviewed the facility assessment dated [DATE] and revised on 02/20/24. The facility assessment does not include ethics and compliance training.
On 02/25/25 at 2:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility had an ethics and compliance program. …
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