| May 15, 2025 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| May 15, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| May 15, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695 |
| May 15, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · F-0726 |
| May 15, 2025 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| May 2, 2024 | E · Potential for more than minimal harm, pattern | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| May 2, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · F-0690 |
| May 2, 2024 | D · Potential for more than minimal harm, isolated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · F-0693 |
| May 2, 2024 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| May 2, 2024 | C · Potential for minimal harm, widespread | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| May 2, 2024 | B · Potential for minimal harm, pattern | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · F-0623 |
| Nov 20, 2023 | ▲ J · Immediate jeopardy, isolated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
| Nov 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint · F-0761 |
| Nov 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint · F-0867 |
| Jan 20, 2023 | F · Potential for more than minimal harm, widespread | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · F-0727 |
| Jan 20, 2023 | F · Potential for more than minimal harm, widespread | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Jan 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · F-0580 |
| Jan 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Jan 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Jan 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760 |
| Jan 20, 2023 | E · Potential for more than minimal harm, pattern | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · F-0600 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Jan 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Jan 20, 2023 | C · Potential for minimal harm, widespread | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Jan 20, 2023 | B · Potential for minimal harm, pattern | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |