| Jun 15, 2026 | 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. · from a complaint · F-0604 |
| Apr 22, 2026 | 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 22, 2026 | 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 |
| Apr 22, 2026 | 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 |
| Apr 22, 2026 | D · Potential for more than minimal harm, isolated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676 |
| Apr 22, 2026 | 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. · from a complaint · F-0677 |
| Apr 22, 2026 | 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. · from a complaint · F-0689 |
| Apr 22, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Apr 22, 2026 | 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 22, 2026 | 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 |
| Apr 22, 2026 | 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 |
| Apr 22, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921 |
| Mar 19, 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. · from a complaint · F-0658 |
| Mar 5, 2025 | ▲ J · Immediate jeopardy, isolated | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint · F-0626 |
| Mar 5, 2025 | ▲ J · Immediate jeopardy, isolated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · from a complaint · F-0675 |
| Feb 11, 2025 | ▲ 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 |
| Feb 11, 2025 | ▲ 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 |
| Feb 11, 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 |
| Feb 11, 2025 | ▲ G · Actual harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. · from a complaint · F-0568 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | 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 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint · F-0919 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint · F-0943 |
| Feb 11, 2025 | F · Potential for more than minimal harm, widespread | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint · F-0947 |
| Feb 11, 2025 | 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. · from a complaint · F-0625 |
| Feb 11, 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 |
| Feb 11, 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 |
| Feb 11, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · from a complaint · F-0800 |
| Feb 11, 2025 | 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. · from a complaint · F-0812 |
| Feb 11, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 11, 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. · from a complaint · F-0561 |
| Feb 11, 2025 | 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. · from a complaint · F-0582 |
| Feb 11, 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 |
| Feb 11, 2025 | 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 |
| Feb 11, 2025 | 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 |
| Feb 11, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Jun 24, 2024 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint · F-0602 |
| Jun 24, 2024 | 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. · from a complaint · F-0689 |
| Dec 21, 2023 | ▲ J · Immediate jeopardy, 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 |
| Jun 29, 2023 | ▲ 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. · F-0686 |
| Jun 29, 2023 | ▲ G · Actual harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Jun 29, 2023 | F · Potential for more than minimal harm, widespread | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · F-0585 |
| Jun 29, 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 |
| Jun 29, 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 |
| Jun 29, 2023 | D · Potential for more than minimal harm, isolated | 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 |
| Jun 29, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Jun 29, 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 |
| Jun 29, 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 |
| Jun 29, 2023 | 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, 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 |
| Jun 29, 2023 | 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, 2023 | D · Potential for more than minimal harm, isolated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676 |
| Jun 29, 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 |
| Jun 29, 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 |
| Jun 29, 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 |
| Jun 29, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Jun 29, 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 |
| Jun 29, 2023 | 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, 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 |
| Jun 29, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · F-0773 |
| Jun 29, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep complete, dated laboratory records in residents' files. · F-0775 |