| Oct 14, 2025 | ▲ G · Actual 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. · from a complaint · F-0656 |
| Oct 14, 2025 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Apr 17, 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. · F-0550 |
| Apr 17, 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 |
| Apr 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Apr 17, 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 |
| Apr 17, 2025 | 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 |
| Apr 17, 2025 | 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 |
| Apr 17, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Apr 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Mar 26, 2024 | ▲ H · Actual harm, pattern | 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 |
| Mar 26, 2024 | ▲ H · Actual harm, pattern | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · F-0607 |
| Mar 26, 2024 | ▲ H · Actual harm, pattern | 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 |
| Mar 26, 2024 | E · Potential for more than minimal harm, pattern | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Mar 26, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · F-0740 |
| Mar 26, 2024 | 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, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Mar 26, 2024 | 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 |
| Jun 29, 2022 | F · Potential for more than minimal harm, widespread | 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 |
| Jun 29, 2022 | E · Potential for more than minimal harm, pattern | 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 |
| Jun 29, 2022 | E · Potential for more than minimal harm, pattern | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · F-0908 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · F-0554 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · F-0604 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · F-0607 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility required residents to give up Medicare or Medicaid benefits or pay privately as a condition of moving in, or failed to tell residents which types of care it does not provide. Both practices are against the rules. · F-0620 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · F-0685 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | 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. · F-0695 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · F-0742 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | 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 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849 |
| Jun 29, 2022 | 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 |
| Jun 29, 2022 | D · Potential for more than minimal harm, isolated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · F-0881 |