| May 13, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| May 13, 2026 | 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 |
| Mar 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint · F-0694 |
| Feb 5, 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. · from a complaint · F-0686 |
| Feb 5, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint · F-0699 |
| Dec 22, 2025 | 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. · from a complaint · F-0812 |
| Dec 22, 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 |
| Dec 3, 2025 | 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 |
| Aug 13, 2025 | 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. · from a complaint · F-0607 |
| Jul 25, 2025 | ▲ J · Immediate jeopardy, 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 |
| Jul 25, 2025 | F · Potential for more than minimal harm, widespread | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. · F-0575 |
| Jul 25, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725 |
| Jul 25, 2025 | F · Potential for more than minimal harm, widespread | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. · F-0728 |
| Jul 25, 2025 | 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 |
| Jul 25, 2025 | 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 |
| Jul 25, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · F-0745 |
| Jul 25, 2025 | E · Potential for more than minimal harm, pattern | 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 |
| Jul 25, 2025 | E · Potential for more than minimal harm, pattern | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · F-0801 |
| Jul 25, 2025 | 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 |
| Jul 25, 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 |
| Jul 25, 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. · F-0600 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · F-0628 |
| Jul 25, 2025 | 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 |
| Jul 25, 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. · F-0677 |
| Jul 25, 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. · F-0684 |
| Jul 25, 2025 | 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 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Jul 25, 2025 | 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 |
| Jul 25, 2025 | 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 |
| Jul 25, 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. · F-0755 |
| Jul 25, 2025 | 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 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. · F-0810 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Jul 25, 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 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · F-0941 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · F-0942 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · F-0943 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · F-0944 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · F-0945 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · F-0946 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | 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 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · F-0949 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint · F-0559 |
| Jul 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' right to refuse certain moves within the nursing home that they did not ask for, such as being switched between units. Residents have a say in where they live inside the facility. · from a complaint · F-0560 |
| May 14, 2025 | 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. · from a complaint · F-0812 |
| May 14, 2025 | 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. · from a complaint · F-0804 |
| May 14, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint · F-0806 |
| May 14, 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 |
| Feb 14, 2025 | 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. · from a complaint · F-0623 |
| Oct 22, 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 |
| Oct 22, 2024 | 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 |
| Oct 22, 2024 | D · Potential for more than minimal 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 |
| Jun 21, 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 |
| Jun 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Jun 21, 2024 | 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. · F-0600 |
| Jun 21, 2024 | 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 |
| Jun 21, 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. · F-0684 |
| Jun 21, 2024 | 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 |
| Jun 21, 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. · F-0689 |
| Jun 21, 2024 | 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. · F-0693 |
| Jun 21, 2024 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Jun 21, 2024 | D · Potential for more than minimal 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 |
| Jun 21, 2024 | 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 |
| Jun 21, 2024 | D · Potential for more than minimal harm, isolated | 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. · F-0809 |
| Jun 21, 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 |
| Jun 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849 |
| Jun 21, 2024 | 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 |
| Jun 21, 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. · from a complaint · F-0692 |
| Mar 27, 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 11, 2024 | D · Potential for more than minimal harm, isolated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580 |
| Jan 24, 2024 | 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 |
| Jan 10, 2024 | ▲ H · Actual harm, pattern | 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 |
| Jan 10, 2024 | ▲ H · Actual harm, pattern | 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 |
| Jan 10, 2024 | ▲ H · Actual harm, pattern | 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 |
| Jan 10, 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 |
| Aug 25, 2023 | F · Potential for more than minimal harm, widespread | 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 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | E · Potential for more than minimal harm, pattern | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · F-0943 |
| Aug 25, 2023 | E · Potential for more than minimal harm, pattern | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · F-0945 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | D · Potential for more than minimal harm, isolated | 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 |
| Aug 25, 2023 | 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. · F-0600 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | 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 |
| Aug 25, 2023 | C · Potential for minimal harm, widespread | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · F-0944 |
| Aug 25, 2023 | B · Potential for minimal harm, pattern | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · F-0941 |
| Aug 25, 2023 | B · Potential for minimal harm, pattern | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · F-0942 |
| Aug 25, 2023 | B · Potential for minimal harm, pattern | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · F-0946 |
| Aug 25, 2023 | B · Potential for minimal harm, pattern | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · F-0949 |