| May 7, 2026 | 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 |
| May 7, 2026 | 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 7, 2026 | 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 7, 2026 | C · Potential for minimal harm, widespread | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · F-0576 |
| Mar 7, 2025 | 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 |
| Mar 7, 2025 | E · Potential for more than minimal harm, pattern | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint · F-0809 |
| Mar 7, 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. · F-0812 |
| Mar 7, 2025 | 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 |
| Mar 7, 2025 | E · Potential for more than minimal harm, pattern | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · F-0887 |
| Mar 7, 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 |
| Mar 7, 2025 | 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 7, 2025 | 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. · F-0565 |
| Mar 7, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0585 |
| Mar 7, 2025 | 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 7, 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 |
| Mar 7, 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 |
| Nov 17, 2023 | E · Potential for more than minimal harm, pattern | 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. · from a complaint · F-0622 |
| Nov 17, 2023 | E · Potential for more than minimal harm, pattern | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint · F-0626 |
| Nov 17, 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 |
| Nov 17, 2023 | 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. · from a complaint · F-0761 |
| Nov 17, 2023 | 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. · from a complaint · F-0803 |
| Nov 17, 2023 | 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 |
| Nov 17, 2023 | 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. · from a complaint · F-0867 |
| Nov 17, 2023 | 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. · from a complaint · F-0578 |
| Nov 17, 2023 | 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. · from a complaint · F-0641 |
| Nov 17, 2023 | 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. · from a complaint · F-0644 |
| Nov 17, 2023 | D · Potential for more than minimal harm, isolated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint · F-0693 |
| Nov 17, 2023 | 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. · from a complaint · F-0695 |
| Nov 17, 2023 | B · Potential for 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. · from a complaint · F-0625 |