| Jun 5, 2025 | 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 |
| Jan 25, 2024 | E · Potential for more than minimal harm, pattern | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. · F-0909 |
| Jan 25, 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 25, 2024 | 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 |
| Jan 25, 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 |
| Jan 25, 2024 | 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 |
| Mar 17, 2022 | ▲ L · Immediate jeopardy, widespread | 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. · F-0678 |
| Mar 17, 2022 | ▲ 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 |
| Mar 17, 2022 | F · Potential for more than minimal harm, widespread | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · F-0563 |
| Mar 17, 2022 | 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. · F-0730 |
| Mar 17, 2022 | 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 |
| Mar 17, 2022 | F · Potential for more than minimal harm, widespread | The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. · F-0841 |
| Mar 17, 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 |
| Mar 17, 2022 | 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 17, 2022 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 17, 2022 | E · Potential for more than minimal harm, pattern | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Mar 17, 2022 | 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 |
| Mar 17, 2022 | E · Potential for more than minimal harm, pattern | 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 |
| Mar 17, 2022 | 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 17, 2022 | 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 |
| Mar 17, 2022 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · F-0610 |
| Mar 17, 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 |
| Mar 17, 2022 | 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 |
| Mar 17, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Mar 17, 2022 | D · Potential for more than minimal 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 |
| Mar 17, 2022 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770 |
| Mar 17, 2022 | 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 |
| Mar 17, 2022 | D · Potential for more than minimal harm, isolated | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. · F-0888 |