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F911: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents

F911 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. It sits in CMS's environmental category.

163citations in the CMS files
64homes cited at least once
33in the 12 months to September 2026
0.0%rated actual harm or immediate jeopardy

CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.

How seriously inspectors rate it

Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 2.5% of F911 citations came from a complaint visit rather than a routine inspection.

  • Immediate jeopardy (J, K, L)0 (0.0%)
  • Actual harm (G, H, I)0 (0.0%)
  • Potential for more than minimal harm (D, E, F)22 (13.5%)
  • Potential for minimal harm (A, B, C)141 (86.5%)

By letter: B 139, C 2, D 10, E 11, F 1.

What inspectors wrote

Three recent F911 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.

Inspectors wrote, May 22, 2025, scope and severity EBased on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 42 bedrooms (Rooms A, B, C, and D). This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to the residents and their visitors residing in Rooms A, B, C, and D.

Colonial Gardens Nursing Home, Pico Rivera, CA

Most recent F911 citations

InspectionHomeTownLetter
April 24, 2026Folsom Care CenterFolsom, CA B
April 16, 2026Brookside Skilled Nursing HospitalSan Mateo, CA B
April 3, 2026Meadowbrook Behavioral Health CenterLos Angeles, CA B
March 27, 2026Monterey Healthcare & Wellness Centre, LPRosemead, CA B
March 20, 2026Grace Healthcare CenterFresno, CA F
March 19, 2026The Rehabilitation Center on PicoLos Angeles, CA B
March 12, 2026Riviera Healthcare CenterPico Rivera, CA B
March 5, 2026Grand Terrace Health Care CenterGrand Terrace, CA B
February 20, 2026Morning Star Post AcuteClovis, CA B
February 13, 2026Osage Healthcare & Wellness CentreInglewood, CA B
February 12, 2026Hillcrest Manor SanitariumNational City, CA B
February 9, 2026Villa Serena Healthcare CenterLong Beach, CA B
February 6, 2026Broadway Healthcare CenterSan Gabriel, CA B
February 6, 2026Virgil Rehabilitation & Skilled Nursing CenterLos Angeles, CA B
January 22, 2026Pavilion on Pico Healthcare & Wellness Centre, LPLos Angeles, CA B
January 9, 2026North Pointe Care CenterSacramento, CA B
January 9, 2026Vineyards at FowlerFowler, CA B
December 19, 2025Manning Gardens Care Center, IncFresno, CA B
December 18, 2025Lakewood Healthcare CenterDowney, CA B
December 18, 2025Lemon Grove Care and Rehabilitation CenterLemon Grove, CA B
December 17, 2025Del Mar Convalescent HospitalRosemead, CA B
December 15, 2025Griffith Park Healthcare CenterGlendale, CA B
December 11, 2025Citrus Grove Post AcuteRiverside, CA B
December 9, 2025Foundation Skilled NursingFresno, CA C
December 4, 2025The Grove Post-Acute Care CenterSylmar, CA B

F911 citations by state

Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.

StateCitations
California160
Alabama3

By inspection year: 2018 1, 2019 2, 2020 1, 2021 10, 2022 12, 2023 21, 2024 51, 2025 48, 2026 17.

Common questions

What is F911 in a nursing home inspection?
F911 is the federal requirement to "ensure resident rooms hold no more than 4 residents; for new construction after november 28, 2016, rooms hold no more than 2 residents". CMS files it under environmental. A home cited under F911 did not meet that requirement at the inspection.
How often is F911 cited?
The CMS files as of September 1, 2026 list 163 F911 citations at 64 nursing homes, 33 of them in the 12 months to that date. 0.0% were rated as actual harm or immediate jeopardy.
Is a F911 citation serious?
It depends on the letter. Most F911 citations (13.5%) were rated as potential for more than minimal harm, D to F. None in the current files is at the immediate jeopardy level.

The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology

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