| Mar 3, 2026 | 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. · F-0804 |
| Mar 3, 2026 | 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 |
| Mar 3, 2026 | D · Potential for more than minimal harm, isolated | 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 3, 2026 | 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 3, 2026 | 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 |
| Mar 3, 2026 | 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 |
| Apr 3, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint · F-0865 |
| Apr 3, 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 |
| Apr 3, 2025 | D · Potential for more than minimal harm, isolated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · from a complaint · F-0637 |
| Apr 3, 2025 | 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. · from a complaint · F-0640 |
| Apr 3, 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. · from a complaint · F-0657 |
| Apr 3, 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 |
| Apr 3, 2025 | 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. · from a complaint · F-0676 |
| Apr 3, 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. · from a complaint · F-0677 |
| Apr 3, 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 |
| Apr 3, 2025 | 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. · from a complaint · F-0686 |
| Apr 3, 2025 | 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 3, 2025 | 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. · from a complaint · F-0758 |
| Apr 3, 2025 | 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. · from a complaint · F-0880 |
| Feb 6, 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. · F-0686 |
| Feb 6, 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 6, 2025 | ▲ G · Actual 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 |
| Feb 6, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · F-0865 |
| Feb 6, 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. · F-0625 |
| Feb 6, 2025 | 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 |
| Feb 6, 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. · F-0656 |
| Feb 6, 2025 | 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 |
| Feb 6, 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 |
| Feb 6, 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 6, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637 |
| Feb 6, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 6, 2025 | 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 |
| Feb 6, 2025 | 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 |
| Feb 6, 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 |
| Feb 6, 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 6, 2025 | 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 |
| Feb 6, 2025 | 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 |
| Feb 6, 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. · from a complaint · F-0842 |
| Feb 6, 2025 | 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 |
| Feb 15, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have enough support staff to safely and effectively run its food and nutrition service. · F-0802 |
| Feb 15, 2024 | F · Potential for more than minimal harm, widespread | 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 |
| Feb 15, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · F-0865 |
| Feb 15, 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 |
| Feb 15, 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 |
| Feb 15, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a compliance and ethics program — an internal system designed to prevent and catch violations of the law and ethical standards. · F-0895 |
| Feb 15, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Feb 15, 2024 | E · Potential for more than minimal harm, pattern | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637 |
| Feb 15, 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 |
| Feb 15, 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 |
| Feb 15, 2024 | 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. · from a complaint · F-0692 |
| Feb 15, 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. · from a complaint · F-0656 |
| Feb 15, 2024 | 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 |
| Feb 15, 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 |
| Feb 15, 2024 | 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 |