| May 20, 2026 | ▲ 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 |
| May 20, 2026 | 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. · from a complaint · F-0584 |
| May 20, 2026 | 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 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint · F-0627 |
| Sep 30, 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 |
| Sep 30, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Sep 30, 2025 | E · Potential for more than minimal harm, 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. · from a complaint · F-0686 |
| Sep 30, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Sep 30, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Sep 30, 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 |
| Sep 30, 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 |
| Sep 30, 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 |
| Sep 30, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552 |
| Sep 30, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Sep 30, 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 |
| Sep 30, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770 |
| Sep 30, 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 |
| Sep 30, 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 |
| May 1, 2024 | ▲ K · Immediate jeopardy, pattern | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint · F-0678 |
| May 1, 2024 | E · Potential for more than minimal harm, pattern | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint · F-0868 |
| Mar 27, 2024 | ▲ K · Immediate jeopardy, 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. · from a complaint · F-0600 |
| Mar 27, 2024 | 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 |
| Mar 27, 2024 | F · Potential for more than minimal harm, widespread | 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 |
| Mar 27, 2024 | F · Potential for more than minimal harm, widespread | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · F-0882 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | 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. · from a complaint · F-0585 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · F-0644 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | 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 27, 2024 | E · Potential for more than minimal harm, pattern | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Mar 27, 2024 | 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. · F-0812 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842 |
| Mar 27, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 27, 2024 | 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 |
| Mar 27, 2024 | 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 |
| Mar 27, 2024 | 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. · from a complaint · F-0565 |
| Mar 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. · F-0640 |
| Mar 27, 2024 | 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 |
| Mar 27, 2024 | 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 |
| Mar 27, 2024 | 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 |
| Mar 27, 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. · F-0689 |
| Mar 27, 2024 | 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 |
| Mar 27, 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 |
| Mar 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · F-0791 |
| Mar 27, 2024 | D · Potential for more than minimal harm, isolated | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · F-0838 |
| Jan 23, 2024 | 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 |
| Jan 23, 2024 | 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 |
| Jan 23, 2024 | 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. · from a complaint · F-0804 |
| Jan 23, 2024 | E · Potential for more than minimal harm, pattern | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842 |
| Jan 23, 2024 | 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 |
| Jan 23, 2024 | 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 |
| Jan 23, 2024 | 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. · from a complaint · F-0609 |
| Jan 23, 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 |
| Sep 25, 2023 | E · Potential for more than minimal harm, pattern | 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 |
| Sep 25, 2023 | 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. · from a complaint · F-0758 |
| Sep 11, 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. · from a complaint · F-0550 |
| Sep 11, 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. · from a complaint · F-0684 |
| Aug 10, 2022 | 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 |
| Aug 10, 2022 | E · Potential for more than minimal harm, pattern | 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 |
| Aug 10, 2022 | E · Potential for more than minimal harm, pattern | 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 |
| Aug 10, 2022 | E · Potential for more than minimal harm, pattern | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Aug 10, 2022 | E · Potential for more than minimal harm, pattern | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Aug 10, 2022 | E · Potential for more than minimal harm, pattern | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Aug 10, 2022 | 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 10, 2022 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578 |
| Aug 10, 2022 | 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. · F-0641 |
| Aug 10, 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 |
| Aug 10, 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 |
| Aug 10, 2022 | 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 |
| Aug 10, 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 |
| Aug 10, 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 |
| Aug 10, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Aug 10, 2022 | 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 |
| Aug 10, 2022 | 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 10, 2022 | 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 |