| Sep 19, 2025 | ▲ J · Immediate jeopardy, isolated | 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 |
| Sep 19, 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 |
| Sep 19, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Sep 19, 2025 | 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 |
| Sep 19, 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 |
| Sep 19, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697 |
| Sep 19, 2025 | 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. · from a complaint · F-0755 |
| Oct 2, 2024 | ▲ 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. · from a complaint · F-0760 |
| May 23, 2024 | 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 |
| May 23, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint · F-0687 |
| May 23, 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. · from a complaint · F-0689 |
| May 23, 2024 | D · Potential for more than minimal harm, isolated | 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 22, 2024 | ▲ K · Immediate jeopardy, pattern | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint · F-0740 |
| Mar 22, 2024 | ▲ K · Immediate jeopardy, pattern | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint · F-0741 |
| Mar 22, 2024 | 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 |
| Mar 22, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint · F-0687 |
| Mar 22, 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. · from a complaint · F-0689 |
| Mar 22, 2024 | D · Potential for more than minimal harm, isolated | 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 |
| May 28, 2021 | ▲ 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 |
| May 28, 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 28, 2021 | F · Potential for more than minimal harm, widespread | 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. · F-0919 |
| May 28, 2021 | E · Potential for more than minimal harm, pattern | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · F-0803 |
| May 28, 2021 | 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 |
| May 28, 2021 | 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 |
| May 28, 2021 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| May 28, 2021 | 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 |
| May 28, 2021 | 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 |
| May 28, 2021 | 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 |
| May 28, 2021 | 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 |
| May 28, 2021 | 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 28, 2021 | 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 |
| Feb 7, 2019 | ▲ 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 |
| Feb 7, 2019 | 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 |
| Feb 7, 2019 | 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. · F-0677 |
| Feb 7, 2019 | 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 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · F-0557 |
| Feb 7, 2019 | 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 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · F-0607 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · F-0622 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | 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 7, 2019 | 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 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 7, 2019 | D · Potential for more than minimal harm, isolated | 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 |
| Feb 7, 2019 | C · Potential for 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 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not give residents proper written notice of their rights, the facility's rules, the services offered, and what those services cost. · F-0156 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not properly protect and manage residents' personal money that was deposited with the nursing home for safekeeping. Facilities that hold residents' funds must keep them secure and accounted for. · F-0159 |
| Jul 13, 2017 | 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-0287 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not provide the care and services each resident needed to stay as healthy and well as possible. · F-0309 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not give residents proper care to prevent new pressure sores (bed sores) or to heal existing ones. Pressure sores are painful skin wounds that develop when someone stays in one position too long, and good nursing care can usually prevent them. · F-0314 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not have an effective program to investigate, control, and prevent the spread of infections. · F-0441 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not keep its grounds and building safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0465 |
| Jul 13, 2017 | E · Potential for more than minimal harm, pattern | The facility did not keep accurate, complete, and organized medical records for each resident that meet professional standards. · F-0514 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not care for residents in a way that maintains their dignity and respect — treating each person as an individual with their own preferences and worth. · F-0241 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not update each resident's assessment at least once every 3 months. Regular updates make sure the care a resident gets keeps up with their changing condition. · F-0276 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not make sure each resident's health assessment was accurate and done by a qualified health professional. · F-0278 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not create a complete written plan of care covering all of a resident's needs, with clear goals, deadlines, and steps whose progress can be measured. · F-0279 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility gave residents urinary catheters when they weren't medically necessary, or failed to give residents with bladder control problems the care needed to prevent urinary tract infections and help restore normal bladder function. · F-0315 |
| Jul 13, 2017 | 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 avoidable accidents like falls. · F-0323 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility's medication error rate — giving the wrong drug, the wrong dose, or medicine at the wrong time — was 5% or higher. Facilities are required to keep these errors below that level. · F-0332 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not keep residents safe from serious medication errors. · F-0333 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not provide routine and emergency medications through a licensed pharmacist, with a licensed nurse overseeing how drugs are handled and given. · F-0425 |
| Jul 13, 2017 | D · Potential for more than minimal harm, isolated | The facility did not keep proper drug records or correctly label medications according to professional standards. Accurate records and labels are how staff know what each medicine is, whose it is, and how to give it safely. · F-0431 |
| Jul 13, 2017 | C · Potential for minimal harm, widespread | The facility did not make the results of its most recent government inspection easy for residents to find and read. Inspection results must be posted where anyone can see them. · F-0167 |