Based on observation, interview, and record review the facility failed to ensure residents'' rooms were located at or above ground level which applies to 24 of 62 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) reviewed for facility enviorment in a sample of 62.The findings include: On 8/5/25 at 10:00 AM 24 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) were observed on the lower-level floor in rooms located below ground level.The facility's memory care roster (100 unit) showed a census of 24 residents.On 8/4/25 at 11:00 AM, V1 Administrator stated the memory care unit (100 unit) rooms are below the level of the ground. …
F916
Environmental Deficiencies
Ensure each resident has a room at or above ground level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F916 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F916 finding.
The harm level
How severely F916 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D— | E327.3% | F— |
| No harm, potential for minimal | A— | B872.7% | C— |
In the surveyor’s words
What an F916 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 observations and interviews, the facility failed to have the floor of the resident rooms at the garden or above the ground level. This applies to 36 of the 36 (R1, R4, R6, R7, R11, R14, R15, R16, R18, R26, R29, R31, R34, R36, R39, R42, R43, R45, R46, R47, R52, R53, R66, R67, R68, R76, R87, R91, R98, R99, R101, R102, R103, R104, R108) residents reviewed for physical environment. The findings include: Residents rooms B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, and B14 are below the below the garden or ground level. On 10/31/2024 AT 11:00 AM, V1 (Administrator) said since its inception, the facility has had the same structure, and every year, the facility receives the deficiency during the annual survey.
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