| May 11, 2026 | ▲ 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 11, 2026 | 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 11, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · F-0805 |
| May 11, 2026 | 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 |
| May 11, 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 |
| May 11, 2026 | 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 11, 2026 | 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 |
| May 11, 2026 | 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 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| May 11, 2026 | 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 |
| May 11, 2026 | 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 |
| May 11, 2026 | C · Potential for minimal harm, widespread | 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 |
| Feb 13, 2025 | F · Potential for more than minimal harm, widespread | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · F-0851 |
| Feb 13, 2025 | 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 |
| Feb 13, 2025 | 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 13, 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. · F-0657 |
| Feb 13, 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 |
| Feb 13, 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. · F-0686 |
| Feb 13, 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. · F-0689 |
| Feb 13, 2025 | 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. · F-0692 |
| Feb 13, 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 13, 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 |
| Feb 13, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Feb 13, 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 |
| Jun 21, 2024 | ▲ L · Immediate jeopardy, widespread | 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 |
| Jun 21, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837 |
| Jun 21, 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. · from a complaint · F-0865 |
| Mar 11, 2024 | ▲ L · Immediate jeopardy, widespread | 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 |
| Mar 11, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837 |
| Mar 11, 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. · from a complaint · F-0865 |
| Jan 31, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837 |
| Jan 31, 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. · from a complaint · F-0865 |
| Dec 18, 2023 | ▲ L · Immediate jeopardy, widespread | 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 |
| Dec 18, 2023 | F · Potential for more than minimal harm, widespread | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837 |
| Sep 14, 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 |
| Sep 14, 2023 | F · Potential for more than minimal harm, widespread | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Sep 14, 2023 | F · Potential for more than minimal harm, widespread | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · F-0908 |
| Sep 14, 2023 | E · Potential for more than minimal harm, pattern | 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 |
| Sep 14, 2023 | E · Potential for more than minimal harm, pattern | 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 |
| Sep 14, 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 |
| Sep 14, 2023 | E · Potential for more than minimal harm, pattern | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · F-0805 |
| Sep 14, 2023 | 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 |
| Sep 14, 2023 | 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 14, 2023 | 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. · from a complaint · F-0610 |
| Sep 14, 2023 | 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 |
| Sep 14, 2023 | 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 |
| Sep 14, 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. · F-0644 |
| Sep 14, 2023 | 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 |
| Sep 14, 2023 | 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. · F-0692 |
| Sep 14, 2023 | 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. · from a complaint · F-0700 |
| Sep 14, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Sep 14, 2023 | 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 |
| Sep 14, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. · F-0807 |
| Sep 14, 2023 | 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 |
| Sep 14, 2023 | D · Potential for more than minimal harm, isolated | 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 |