of F940 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025106
Every F940 citation surveyors wrote nationally that year.
Facilities cited106
Distinct nursing homes with at least one F940 finding.
The harm level
How severely F940 is cited
1.2% 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—
K20.6%
L—
Actual harm
G20.6%
H—
I—
No harm, potential for more than minimal
D11934.6%
E13840.1%
F7722.4%
No harm, potential for minimal
A—
B10.3%
C51.5%
Every recorded F940 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F940 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.
K · Immediate jeopardy, patternNovember 7, 2023
Based on document review and staff interviews, the facility failed to ensure that they implemented and maintained an effective training program for all new hires, consistent with their expected roles, and failed to determine the amount and type of training necessary based on the facility assessment. Specifically, 22 out of 22 new staff hired in 2023 to date, were not provided training, therefore, failing to ensure competent, safe, and effective resident care.
Findings include:
Review of the Facility Assessment indicated the following:
-3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. …
Based on interview and record review the facility failed to ensure that an effective training program for newly hired nurses was provided and monitored for all newly hired nurses in 1 of 1 resident (Resident #1) reviewed for training, resulting in a delay in treatment and emergent hospital transfer for Resident #1. Findings include:Resident #1Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 03:16 AM (3:16 am) and authored by Registered Nurse (RN) V at 8:19 am on [DATE] revealed .PA (physician assistant) notified of patient's change in condition, including hypotension (83/56 BP Blood pressure).lethargy, cool skin, significant bilateral lower-extremity edema, and blue-to purplish fluid-filled blisters on posterior heels bilaterally. …
F · No harm, potential for more than minimal, widespreadSeptember 2, 2026
Based on clinical record reviews, review of facility documentation, review of facility policies and procedures, and staff interviews, the facility failed to develop and/or implement an effective training program to ensure nursing staff received education necessary to provide care and services related to the prevention, identification, and treatment of pressure ulcers/injuries. The findings inlcude:The review of the Facility Assessment, last updated 4/1/26, found that at any given time, 15 to 20 residents in the facility were dependent on staff for all mobility needs, which increased their risk of pressure ulcer/injury development. …
C · No harm, potential for minimal, widespreadJuly 24, 2026
Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on emergency preparedness annually to all staff members.Findings include:Review of the United States Code of Federal Regulations S483.73(d)(ii) Emergency Preparedness indicated, The LTC (long-term care) facility must: Provide emergency preparedness training at least annually and Maintain documentation of the training.During an interview on 7/23/26, at approximately 12:46 p.m. the Director of Maintenance Employee E18 confirmed that emergency preparedness training is only provided during new-employee orientation and is not completed annually with each staff member.During an interview on 7/23/26, at approximately 2:00 p.m. …
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide and implement an infection prevention and control program.
Cited in the same inspection, not caused by one another.
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