| May 12, 2026 | E · Potential for more than minimal harm, pattern | 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. · from a complaint · F-0657 |
| May 12, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Aug 7, 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 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · F-0628 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · F-0645 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Aug 7, 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 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · F-0561 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679 |
| Aug 7, 2025 | 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 |
| Aug 7, 2025 | D · Potential for more than minimal 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. · F-0760 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925 |
| Nov 26, 2024 | ▲ G · Actual 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. · from a complaint · F-0600 |
| Nov 26, 2024 | ▲ 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 |
| Nov 26, 2024 | ▲ G · Actual harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Oct 2, 2024 | ▲ 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 2, 2024 | ▲ G · Actual 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. · from a complaint · F-0686 |
| Oct 2, 2024 | 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. · from a complaint · F-0641 |
| Oct 2, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Nov 15, 2023 | ▲ 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. · F-0656 |
| Nov 15, 2023 | ▲ G · Actual harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Nov 15, 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 |
| Nov 15, 2023 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · F-0561 |
| Nov 15, 2023 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Nov 15, 2023 | 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. · F-0623 |
| Nov 15, 2023 | 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 |
| Nov 15, 2023 | D · Potential for more than minimal harm, isolated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · F-0645 |
| Nov 15, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0677 |
| Nov 15, 2023 | 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 |
| Nov 15, 2023 | D · Potential for more than minimal harm, isolated | 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 |
| Apr 23, 2021 | 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 23, 2021 | 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 |
| Apr 23, 2021 | D · Potential for more than minimal harm, isolated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · F-0687 |
| Apr 23, 2021 | 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 23, 2021 | D · Potential for more than minimal harm, isolated | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. · F-0850 |