| Sep 11, 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. · from a complaint · F-0689 |
| Jun 5, 2025 | E · Potential for more than minimal 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 |
| Feb 26, 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 |
| Feb 26, 2025 | F · Potential for more than minimal harm, widespread | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint · F-0838 |
| Feb 26, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. · from a complaint · F-0843 |
| Feb 26, 2025 | 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. · from a complaint · F-0584 |
| Feb 26, 2025 | E · Potential for more than minimal 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 |
| Feb 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. · from a complaint · F-0568 |
| May 15, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| May 15, 2024 | 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 15, 2024 | 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. · from a complaint · F-0561 |
| May 15, 2024 | 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 |
| May 15, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint · F-0791 |
| May 15, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · F-0908 |
| Oct 18, 2023 | 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 |
| Sep 6, 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. · from a complaint · F-0600 |
| Jan 24, 2023 | F · Potential for more than minimal harm, widespread | 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 |
| Jan 24, 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 |
| Jan 24, 2023 | F · Potential for more than minimal harm, widespread | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · F-0882 |
| Jan 24, 2023 | E · Potential for more than minimal harm, pattern | 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 |
| Jan 24, 2023 | 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 |
| Jan 24, 2023 | E · Potential for more than minimal 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. · F-0600 |
| Jan 24, 2023 | E · Potential for more than minimal harm, pattern | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · F-0726 |
| Jan 24, 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. · F-0761 |
| Jan 24, 2023 | E · Potential for more than minimal harm, pattern | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Jan 24, 2023 | E · Potential for more than minimal harm, pattern | The facility did not perform required COVID-19 testing on residents and staff. · F-0886 |
| Jan 24, 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 |
| Jan 24, 2023 | D · Potential for more than minimal harm, isolated | The facility did not notify the appropriate authorities when a resident with a mental disorder or intellectual disability had a significant change in condition. · F-0646 |
| Jan 24, 2023 | 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. · F-0658 |
| Jan 24, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive. · F-0659 |
| Jan 24, 2023 | D · Potential for more than minimal harm, isolated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676 |
| Jan 24, 2023 | 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 |
| Jan 24, 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. · F-0695 |
| Jan 24, 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. · F-0700 |
| Jan 24, 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 |
| Jan 24, 2023 | 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 |
| Dec 2, 2021 | ▲ G · Actual 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 |
| Dec 2, 2021 | E · Potential for more than minimal 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. · F-0600 |
| Dec 2, 2021 | 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. · F-0809 |
| Dec 2, 2021 | E · Potential for more than minimal harm, pattern | The facility did not perform required COVID-19 testing on residents and staff. · F-0886 |
| Dec 2, 2021 | 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 |
| Dec 2, 2021 | 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 |