| May 27, 2025 | ▲ G · Actual harm, isolated | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint · F-0711 |
| May 27, 2025 | ▲ G · Actual harm, 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 |
| May 27, 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. · from a complaint · F-0726 |
| Mar 26, 2025 | ▲ H · Actual harm, pattern | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725 |
| Mar 26, 2025 | F · Potential for more than minimal harm, widespread | 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 |
| Mar 26, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. · F-0923 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 26, 2025 | 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. · F-0761 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Mar 26, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint · F-0622 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | 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. · from a complaint · F-0623 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625 |
| Mar 26, 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 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · F-0675 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Mar 26, 2025 | 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 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
| Mar 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure that paid feeding assistants — staff hired to help residents eat and drink — had the training they need. · F-0948 |
| Apr 17, 2024 | F · Potential for more than minimal harm, widespread | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · F-0801 |
| Apr 17, 2024 | E · Potential for more than minimal harm, pattern | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625 |
| Apr 17, 2024 | D · Potential for more than minimal harm, isolated | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · F-0661 |
| May 26, 2023 | F · Potential for more than minimal harm, widespread | 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 26, 2023 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| May 26, 2023 | E · Potential for more than minimal harm, pattern | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · F-0803 |
| May 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · F-0582 |
| May 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · F-0610 |
| May 26, 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 |
| May 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · F-0744 |
| May 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · F-0808 |
| May 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. · F-0810 |