Safety Report: Bridgewood Health Care Center

Kansas City, Missouri · Based on official CMS inspection records as of October 1, 2026.

How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★

Health inspections★★★★★

Staffing★★★★★

Quality measures★★★★★

Long-stay quality★★★★★

Short-stay qualityNo rating

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

12Immediate jeopardy citations (severity J–L)

14Actual harm citations (severity G–I)

24Requirements cited on more than one inspection

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 19, 2026, during a complaint investigation. Facility reported correction by May 31, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 6, 2026, during a complaint investigation. Facility reported correction by May 25, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of April 22, 2026, during a complaint investigation. Facility reported correction by May 6, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of April 14, 2026, during a complaint investigation. Facility reported correction by May 25, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of April 14, 2026, during a complaint investigation. Facility reported correction by May 25, 2026.

Quality of Life and Care Deficiencies · Tag F740

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of March 20, 2026, during a complaint investigation. Facility reported correction by May 1, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of March 12, 2026, during a complaint investigation. Facility reported correction by April 12, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of March 12, 2026, during a complaint investigation. Facility reported correction by April 12, 2026.

Quality of Life and Care Deficiencies · Tag F740

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to residents (not immediate jeopardy).” The problem affected more than a very small number of residents, or happened repeatedly. Inspection of February 26, 2026, during a complaint investigation. Facility reported correction by June 1, 2026.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 26, 2026, during a complaint investigation. Facility reported correction by June 1, 2026.

Quality of Life and Care Deficiencies · Tag F740

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of January 8, 2026, during a complaint investigation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of December 22, 2025, during a complaint investigation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 25, 2025, during a complaint investigation. Facility reported correction by November 26, 2025.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of August 22, 2025, during a complaint investigation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of March 5, 2025, during a complaint investigation. Facility reported correction by March 10, 2025.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected more than a very small number of residents, or happened repeatedly. Inspection of January 31, 2025, during a complaint investigation. Facility reported correction by March 10, 2025.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 15, 2024, during a complaint investigation. Facility reported correction by November 5, 2024.

Quality of Life and Care Deficiencies · Tag F689

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of September 12, 2024, during a complaint investigation. Facility reported correction by October 27, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of July 31, 2024, during a complaint investigation. Facility reported correction by July 22, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected more than a very small number of residents, or happened repeatedly. Inspection of June 25, 2024, during a complaint investigation. Facility reported correction by July 25, 2024.

Resident Rights Deficiencies · Tag F584

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of May 3, 2024, during a complaint investigation. Facility reported correction by April 26, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 9, 2024, during a complaint investigation. Facility reported correction by February 5, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of December 21, 2023, during a complaint investigation. Facility reported correction by February 5, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 30, 2023, during a complaint investigation. Facility reported correction by February 5, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 16, 2023, during a complaint investigation. Facility reported correction by February 5, 2024.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of October 18, 2023, during a complaint investigation. Facility reported correction by October 10, 2023.

Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Citations by topic

37Abuse, neglect & exploitation

8Infection control

10Medications & pharmacy

6Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

The same number of citations in the most recent cycle as in the cycle before (44).

Two cycles ago
9 serious

Prior cycle
4 serious

Most recent cycle
13 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

Requirement	Times cited	Inspection dates
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600)	25	July 15, 2026; May 19, 2026; May 6, 2026; April 22, 2026; April 14, 2026; March 20, 2026; March 12, 2026; February 26, 2026; January 8, 2026; December 22, 2025; November 25, 2025; August 22, 2025; April 28, 2025; March 5, 2025; January 31, 2025; December 19, 2024; September 12, 2024; July 31, 2024; May 3, 2024; February 9, 2024; December 21, 2023; November 30, 2023; November 16, 2023; October 18, 2023; May 7, 2023
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (F740)	8	July 31, 2026; April 14, 2026; March 12, 2026; February 26, 2026; January 8, 2026; April 28, 2025; December 19, 2024; October 4, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609)	6	August 24, 2026; March 12, 2026; March 5, 2025; May 3, 2024; November 16, 2023; May 27, 2021
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F584)	6	February 26, 2026; July 31, 2025; April 28, 2025; June 25, 2024; May 30, 2024; May 27, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689)	6	April 28, 2025; November 15, 2024; September 12, 2024; August 15, 2024; February 9, 2024; December 21, 2023
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (F557)	5	August 29, 2025; March 5, 2025; August 15, 2024; May 30, 2024; October 6, 2023
Respond appropriately to all alleged violations. (F610)	3	April 14, 2026; January 31, 2025; November 16, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F761)	3	April 28, 2025; May 7, 2023; May 27, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F756)	3	April 28, 2025; May 7, 2023; May 27, 2021
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. (F741)	3	January 31, 2025; February 9, 2024; October 18, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580)	3	January 3, 2025; December 19, 2024; August 15, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F921)	2	February 26, 2026; April 28, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550)	2	August 22, 2025; November 16, 2023
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (F947)	2	April 28, 2025; May 7, 2023
Provide and implement an infection prevention and control program. (F880)	2	April 28, 2025; May 7, 2023
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. (F887)	2	April 28, 2025; May 7, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations. (F883)	2	April 28, 2025; May 7, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F758)	2	April 28, 2025; May 27, 2021
Provide safe and appropriate respiratory care for a resident when needed. (F695)	2	April 28, 2025; May 7, 2023
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. (F691)	2	April 28, 2025; May 7, 2023
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (F604)	2	January 3, 2025; May 27, 2021
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (F623)	2	September 12, 2024; December 21, 2023
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. (F742)	2	June 25, 2024; May 7, 2023
Provide activities to meet all resident's needs. (F679)	2	May 7, 2023; May 27, 2021

Fines and enforcement

Date	Type	Amount / length
February 26, 2026	Payment Denial	Payment denial for 53 days, starting April 9, 2026
February 26, 2026	Fine	$564,745
January 8, 2026	Fine	$14,895
December 22, 2025	Fine	$14,939
November 20, 2025	Fine	$25,012
July 31, 2025	Fine	$12,627
April 28, 2025	Payment Denial	Payment denial for 6 days, starting June 6, 2025
April 28, 2025	Fine	$14,768
December 19, 2024	Fine	$161,129
November 15, 2024	Fine	$12,038
August 15, 2024	Payment Denial	Payment denial for 11 days, starting October 16, 2024
August 15, 2024	Fine	$51,266
July 31, 2024	Fine	$14,050
May 30, 2024	Fine	$54,406
May 3, 2024	Fine	$16,801
November 16, 2023	Payment Denial	Payment denial for 93 days, starting December 27, 2023
November 16, 2023	Fine	$192,133

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

127 citations across 38 inspection dates.

August 24, 2026 — 1 citation · complaint investigation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected September 11, 2026

July 31, 2026 — 2 citations · complaint investigation

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · complaint

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint

July 15, 2026 — 1 citation · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected July 8, 2026

May 19, 2026 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 31, 2026

May 6, 2026 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 25, 2026

April 22, 2026 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 6, 2026

April 14, 2026 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 25, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F740 · complaint · corrected May 25, 2026

Respond appropriately to all alleged violations.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected May 25, 2026

March 20, 2026 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 1, 2026

March 12, 2026 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 12, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F740 · complaint · corrected April 12, 2026

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 12, 2026

February 26, 2026 — 4 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to residents (not immediate jeopardy) · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 1, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F740 · complaint · corrected June 1, 2026

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F921 · complaint · corrected June 1, 2026

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected June 1, 2026

January 8, 2026 — 2 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · complaint

December 22, 2025 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint

November 25, 2025 — 2 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected November 26, 2025

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F949 · complaint · corrected November 26, 2025

November 20, 2025 — 1 citation · complaint investigation

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected November 21, 2025

August 29, 2025 — 1 citation · complaint investigation

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F557 · complaint · corrected October 13, 2025

August 22, 2025 — 5 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint

Hire a qualified full-time social worker in a facility with more than 120 beds.

No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F850 · complaint · corrected October 6, 2025

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F563 · complaint · corrected October 6, 2025

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · complaint · corrected October 6, 2025

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected October 6, 2025

July 31, 2025 — 3 citations · complaint investigation

Provide a bathroom in or located near each resident’s room.

No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F918 · complaint · corrected September 12, 2025

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F628 · complaint · corrected September 25, 2025

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected September 12, 2025

April 28, 2025 — 20 citations

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F947 · corrected June 12, 2025

Provide and implement an infection prevention and control program.

No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected June 12, 2025

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F921 · corrected June 12, 2025

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F887 · corrected June 12, 2025

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected June 12, 2025

Implement a program that monitors antibiotic use.

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F881 · complaint · corrected June 12, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected June 12, 2025

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected June 12, 2025

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F712 · corrected June 12, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected June 12, 2025

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected June 12, 2025

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected June 12, 2025

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected June 12, 2025

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected June 12, 2025

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · complaint · corrected June 12, 2025

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected June 12, 2025

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F691 · corrected June 12, 2025

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected June 12, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected June 12, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 12, 2025

March 5, 2025 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected March 10, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected February 25, 2025

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected February 26, 2025

January 31, 2025 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected March 10, 2025

Respond appropriately to all alleged violations.

No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected March 10, 2025

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F741 · complaint · corrected March 10, 2025

January 3, 2025 — 2 citations · complaint investigation

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · complaint · corrected February 14, 2025

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected February 14, 2025

December 19, 2024 — 5 citations · complaint investigation

Ensure that residents are free from significant medication errors.

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected February 2, 2025

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F740 · complaint · corrected February 2, 2025

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F622 · complaint · corrected February 2, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected March 10, 2025

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · complaint · corrected February 14, 2025

November 15, 2024 — 1 citation (includes serious) · complaint investigation

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected November 5, 2024

October 4, 2024 — 1 citation · complaint investigation

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F740 · complaint · corrected October 4, 2024

September 12, 2024 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected October 27, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected October 27, 2024

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · complaint · corrected October 27, 2024

August 15, 2024 — 4 citations · complaint investigation

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F744 · complaint · corrected September 27, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 4, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected September 27, 2024

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected September 27, 2024

July 31, 2024 — 1 citation (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected July 22, 2024

June 25, 2024 — 2 citations (includes serious) · complaint investigation

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Immediate jeopardy to resident health or safety · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected July 25, 2024

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F742 · complaint · corrected July 25, 2024

May 30, 2024 — 2 citations · complaint investigation

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected July 25, 2024

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected June 30, 2024

May 3, 2024 — 2 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 26, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 25, 2024

February 9, 2024 — 3 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected February 5, 2024

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F741 · complaint · corrected March 29, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected January 20, 2024

December 21, 2023 — 5 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected February 5, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected January 20, 2024

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F646 · complaint · corrected January 30, 2024

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F626 · complaint · corrected January 25, 2024

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · complaint · corrected January 25, 2024

November 30, 2023 — 2 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected February 5, 2024

Keep residents' personal and medical records private and confidential.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · complaint · corrected December 30, 2023

November 16, 2023 — 4 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected February 5, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected December 25, 2023

Respond appropriately to all alleged violations.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected December 25, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected December 25, 2023

October 18, 2023 — 2 citations (includes serious) · complaint investigation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected October 10, 2023

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F741 · complaint · corrected October 13, 2023

October 6, 2023 — 1 citation · complaint investigation

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected October 4, 2023

May 7, 2023 — 20 citations

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F947 · corrected June 21, 2023

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F887 · corrected June 21, 2023

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected June 21, 2023

Provide and implement an infection prevention and control program.

No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected June 21, 2023

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected June 21, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected June 21, 2023

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F742 · corrected June 21, 2023

Observe each nurse aide's job performance and give regular training.

No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F730 · corrected June 21, 2023

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected June 21, 2023

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F699 · corrected June 21, 2023

Provide activities to meet all resident's needs.

No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected June 21, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected June 21, 2023

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F644 · corrected June 21, 2023

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F565 · corrected June 21, 2023

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected June 21, 2023

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected June 21, 2023

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F691 · corrected June 21, 2023

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected June 21, 2023

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F553 · corrected June 21, 2023

Ensure staff are vaccinated for COVID-19

No actual harm, potential for minimal harm · Widespread · Infection Control Deficiencies · F888 · corrected June 21, 2023

May 27, 2021 — 8 citations

Keep all essential equipment working safely.

No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · corrected July 7, 2021

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected July 7, 2021

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F756 · corrected July 7, 2021

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected July 7, 2021

No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected July 7, 2021

Provide activities to meet all resident's needs.

No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected July 7, 2021

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected July 7, 2021

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected July 7, 2021

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare