of F813 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025189
Every F813 citation surveyors wrote nationally that year.
Facilities cited189
Distinct nursing homes with at least one F813 finding.
The harm level
How severely F813 is cited
0.1% 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
J10.1%
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D43058.0%
E23231.3%
F658.8%
No harm, potential for minimal
A—
B30.4%
C111.5%
Every recorded F813 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F813 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, isolatedApril 30, 2024
Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received care and monitoring of the resident's food consumption within the guidelines of the diet order by failing to:
- Implement the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, that food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 8 (Resident #48) personal refrigerator in that: The facility failed to ensure Resident #48's personal refrigerator's ice box was no frozen with a chunk of ice around it on 8/25/2026 and 8/27/2026.This could place residents at risk to get sick with food borne illnesses.Findings included:Record review of Resident #48's admission Record, dated 8/28/2026, reflected an 81year old female, admitted on [DATE], with diagnose of cognitive communication deficit.Record review of Resident #48's Quarterly MDS Assessment, dated 6/19/2026, reflected her BIMS score… …
C · No harm, potential for minimal, widespreadJuly 22, 2026
Based on interview and document review the facility lacked a policy for personal food storage. This had the opportunity to affect all 13 residents currently residing at the facility.Findings include:During an observation on 7/15/26 at 10:45 a.m., evidence of rodent feces was present in resident rooms and throughout the facility. Fruit, bakery items, leftover meals, crackers and granola bars were stored in residents' rooms.During an interview on 7/15/26 at 1:00 p.m., the facility owner stated they had an ongoing rodent infestation.During an interview on 7/15/26 at 1:30 p.m., the contracted exterminator stated he had concerns with residents maintaining food caches in their rooms related to the rodent infestation.During an interview on 7/15/26 at 2:40 p.m., the DON stated she made complaints… …
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Cited in the same inspection, not caused by one another.
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