Deficiency Index

F921 · Safe, clean, comfortable environment

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations in 2025919

Every F921 citation surveyors wrote nationally that year.

Facilities cited839

Distinct nursing homes with at least one F921 finding.

The harm level

How severely F921 is cited

0.5% 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.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ20.1%K50.1%L70.2%
Actual harmG40.1%H—I—
No harm, potential for more than minimalD1,28335.5%E1,51341.8%F73020.2%
No harm, potential for minimalA—B310.9%C441.2%
Every recorded F921 citation, by the harm level and scope the surveyor assigned.

In the surveyor’s words

What an F921 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, patternFebruary 3, 2026

Facility failures resulted in two deficient practices.A. Based on observation, interview, and record review, the facility failed to provide adequate heating to the St. [NAME]/100 Hallway and rooms and failed to follow facility emergency protocol. These failures have caused R1 to have increased pain from muscle spasms due to being tense from the cold. These failures have the potential to affect all 31 residents residing on St. [NAME] wing, R1, and R3-R32. This failure resulted in an Immediate Jeopardy.B. Based on observation, interview, and record review the facility failed to provide adequate hot water to the entire building. This has the potential to affect all 59 residents residing in the facility. Findings include:A. The Immediate Jeopardy began on 1/12/26 around 8:00 AM. …

Lacon Rehab and Nursing · Illinois

G · Actual harm, isolatedNovember 19, 2025

Based on observation, interview, and record review, the facility failed to ensure a light fixture was in safe operating order. This failure resulted in the light fixture falling from the ceiling, landing on the resident while in bed, and R1 sustaining a second degree burn. This applies to 1 of 3 residents (R1) reviewed for safe physical environment in the sample of 3.The findings include:R1' s electronic face sheet documents R1 has diagnoses that include peripheral vascular diseases, left leg amputee, and hypertension.R1's facility assessment, dated 10/3/25, show R1 has no cognitive impairment.R1's Emergency Department (ED note), dated 10/6/25, documents, Patient presented from facility burned to right upper arm. …

Elevate Care Waukegan · Illinois

E · No harm, potential for more than minimal, patternSeptember 8, 2026

Based on observations and staff interviews, the facility failed to maintain clean and sanitary nourishment rooms for 2 of 2 nourishment rooms reviewed for environment (Nourishment room [ROOM NUMBER] and Nourishment room [ROOM NUMBER]). The findings included: a. On 8/31/26 at 10:40 AM the following observations of Nourishment room [ROOM NUMBER] were made with the presence of the Dietary Manager:The cabinet under the sink, located to the side of the ice machine in Nourishment room [ROOM NUMBER], revealed moisture damage and buckling, to the lower right side of the cabinet. The inside of the cabinet revealed moisture damage and blackish brown spots of matter on the floor and right-side wall of the cabinets. …

Belaire Health Care Center · North Carolina

C · No harm, potential for minimal, widespreadJuly 28, 2026

Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry. Findings included: - On 07/28/2026 at 08:19 AM, laundry tour with Housekeeping/Laundry staff U revealed the following items in need of repair in the laundry:The ceiling had an approximate 18-inch by 18-inch unsealed/unfinished sheetrock patch with an approximate one foot by two-inch linear brown section surrounded with approximate four inch unfinished spackling compound. The laundry exit door had a missing door facing/jam surrounding the three sides of the door, exposing irregular, unfinished bare sheetrock through which laundry staff passed to transport laundry. …

Arma Operator, LLC · Kansas

By state — 2025

Where F921 is cited more, and less, than expected

Each state is measured against its own expected share, not against other states.

Magenta is cited more often than expected, blue less often.

Co-occurrence

Cited alongside F921

Of the 2025 surveys that cited F921, these tags appeared in the same inspection more often than chance would predict.

Cited in the same inspection, not caused by one another.

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