| Apr 13, 2026 | ▲ K · Immediate jeopardy, pattern | 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 |
| Apr 13, 2026 | F · Potential for more than minimal harm, widespread | 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 |
| Apr 13, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Apr 13, 2026 | 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 |
| Apr 13, 2026 | E · Potential for more than minimal harm, pattern | 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 |
| Apr 13, 2026 | 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 |
| Apr 13, 2026 | 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 |
| Apr 13, 2026 | 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 |
| Apr 13, 2026 | D · Potential for more than minimal harm, isolated | 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 |
| Apr 13, 2026 | 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 |
| Apr 13, 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 |
| Apr 13, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770 |
| Apr 13, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0865 |
| Apr 13, 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 |
| Apr 13, 2026 | 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 |
| Sep 17, 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. · from a complaint · F-0550 |
| Sep 17, 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. · from a complaint · F-0656 |
| Sep 17, 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 |
| Apr 21, 2022 | 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. · F-0580 |
| Apr 21, 2022 | 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 |
| Apr 21, 2022 | 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 |
| Apr 21, 2022 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |