| Jun 30, 2026 | 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 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint · F-0770 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them. · from a complaint · F-0776 |
| Feb 27, 2025 | E · Potential for more than minimal harm, pattern | 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. · from a complaint · F-0657 |
| Oct 3, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Oct 3, 2024 | 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 |
| Oct 3, 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. · F-0580 |
| Oct 3, 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 |
| Oct 3, 2024 | 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 |
| Oct 3, 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 |
| Aug 15, 2024 | ▲ G · Actual 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 |
| May 6, 2024 | ▲ J · Immediate jeopardy, isolated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · F-0678 |
| May 6, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| May 6, 2024 | E · Potential for more than minimal harm, pattern | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| May 6, 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. · F-0580 |
| May 6, 2024 | 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 |
| May 6, 2024 | 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 |
| May 6, 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. · F-0656 |
| May 6, 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 |
| May 6, 2024 | 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 |
| Mar 26, 2024 | E · Potential for more than minimal harm, pattern | 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 |
| Feb 28, 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. · from a complaint · F-0686 |
| Feb 28, 2024 | 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 |
| Jan 17, 2024 | 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. · from a complaint · F-0558 |
| Jan 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 5, 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 |
| Jun 16, 2023 | ▲ 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. · F-0689 |
| Jun 16, 2023 | ▲ G · Actual 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 16, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Jun 16, 2023 | E · Potential for more than minimal harm, pattern | 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 |
| Jun 16, 2023 | 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 |
| Jun 16, 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 |
| Jun 16, 2023 | 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 |
| Jun 16, 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 |
| Jun 16, 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 |
| Jun 16, 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 |
| Jun 16, 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. · F-0693 |
| Jun 16, 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 |
| Jun 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · F-0740 |
| Jun 16, 2023 | 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 |
| Jun 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770 |
| Jun 16, 2023 | C · Potential for minimal harm, widespread | 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 |