| Oct 24, 2024 | ▲ 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 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | 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 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · F-0851 |
| Oct 24, 2024 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Oct 24, 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 |
| Oct 24, 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 |
| Oct 24, 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 |
| Oct 24, 2024 | 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. · F-0947 |
| Oct 24, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | 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. · F-0625 |
| Oct 24, 2024 | E · Potential for more than minimal harm, pattern | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · F-0638 |
| Oct 24, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Oct 24, 2024 | 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. · F-0657 |
| Oct 24, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Oct 24, 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 |
| Oct 24, 2024 | E · Potential for more than minimal harm, pattern | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
| Oct 24, 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. · F-0550 |
| Oct 24, 2024 | D · Potential for more than minimal 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Oct 24, 2024 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · F-0712 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | 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 |
| Oct 24, 2024 | C · Potential for minimal harm, widespread | 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 |
| Dec 7, 2022 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Dec 7, 2022 | F · Potential for more than minimal harm, widespread | 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. · F-0868 |
| Dec 7, 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 |
| Dec 7, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688 |
| Dec 7, 2022 | 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 7, 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 |
| Dec 7, 2022 | 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 |
| May 27, 2021 | ▲ K · Immediate jeopardy, pattern | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| May 27, 2021 | 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 |
| May 27, 2021 | 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 |