| Dec 4, 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. · F-0550 |
| Dec 4, 2025 | 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 |
| Dec 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · F-0887 |
| Dec 5, 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 |
| Dec 5, 2024 | 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 |
| Dec 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · F-0805 |
| Dec 5, 2024 | 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 |
| Dec 15, 2023 | ▲ K · Immediate jeopardy, pattern | 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 |
| Dec 15, 2023 | ▲ J · Immediate jeopardy, 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 |
| Dec 15, 2023 | ▲ J · Immediate jeopardy, isolated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| Dec 15, 2023 | ▲ G · Actual harm, isolated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655 |
| Dec 15, 2023 | ▲ 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. · F-0689 |
| Dec 15, 2023 | ▲ G · Actual 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 |
| Dec 15, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Dec 15, 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. · F-0761 |
| Dec 15, 2023 | 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 |
| Dec 15, 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 |
| Dec 15, 2023 | 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 |
| Dec 15, 2023 | D · Potential for more than minimal harm, isolated | 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 |
| Dec 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 |
| Dec 15, 2023 | 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. · F-0684 |
| Dec 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 |
| Dec 15, 2023 | 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 |
| Dec 15, 2023 | D · Potential for more than minimal harm, isolated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · F-0700 |
| Dec 15, 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 |
| Dec 15, 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 |
| Dec 15, 2023 | 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 |
| Dec 15, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806 |
| Dec 15, 2023 | 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 |