of F913 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251
Every F913 citation surveyors wrote nationally that year.
Facilities cited1
Distinct nursing homes with at least one F913 finding.
The harm level
How severely F913 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
D133.3%
E—
F—
No harm, potential for minimal
A—
B266.7%
C—
Every recorded F913 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F913 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, patternSeptember 16, 2021
Based on observations, interviews, and record reviews, the facility failed to ensure that resident rooms had direct access to an exit corridor when four of four Resident rooms (rooms 15, 17, 19 and 21) in the red zone (rooms with confirmed COVID -19 a contagious virus) had been drilled shut.
This had the potential to result in three residents (Resident 1, Resident 2 and Resident 3) who were dependent on staff, being trapped in their rooms in the event of a fire, causing severe [CONDITION(S)], permanent disability or even death.
Findings:
During an observation on September 16, 2021, at 9:20 AM, four Resident rooms, (Room 15, Room 17, Room 19 and Room 21) were noted to have doors that had been drilled closed with a screw. …
D · No harm, potential for more than minimal, isolatedOctober 3, 2024
Based on observations, interviews and record review, the facility failed to ensure residents had direct access to an exit corridor from their designated room space in a room shared by 4 residents for 4 of the 4 residents reviewed (Resident #29, Resident # 60, Resident #64 and Resident #92). Resident #64 would need to exit through Resident #29's designated room space to exit the room and access the hall. Resident #60 would need to exit through either Resident # 64's space and then into Resident #29's designated space or would need to exit through Resident #92's designated space. …
B · No harm, potential for minimal, patternFebruary 7, 2025
Based on observation. interview, and record review the facility failed to ensure four of 40 resident's bedrooms (Rooms 4, 5, 16, and 17) had direct access to the exit corridor without passing through another resident's bedroom.
This deficient practice had the potential to affect the privacy, health and safety of the residents in the room due lack of direct access to an exit during an emergency.
Findings:
During tour of the facility on 2/7/2025 at 11:05 AM, Rooms 4, 5, 16, and 17 did not have direct access into an exit corridor. Residents in rooms [ROOM NUMBERS] had to enter room [ROOM NUMBER], and rooms [ROOM NUMBERS] had to enter room [ROOM NUMBER] to get to the nearest exit corridor. …
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