Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, potential for more than minimal harm
38 citations on record, 8 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.
A–C
No harm, minimal potential
D–F
No harm, potential for harm
G–I
Actual harm to a resident
J–L
Immediate jeopardy
The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.
| Year | Citations | Involving harm or jeopardy |
|---|---|---|
| 2026 | 9 | 2 |
| 2025 | 11 | 0 |
| 2024 | 11 | 3 |
| 2023 | 7 | 3 |
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, potential for more than minimal harm
Respond appropriately to all alleged violations.
No actual harm, potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, potential for more than minimal harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Actual harm to a resident
Provide care by qualified persons according to each resident's written plan of care.
Actual harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, potential for more than minimal harm
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, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
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, potential for more than minimal harm
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, potential for more than minimal harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, potential for more than minimal harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, potential for more than minimal harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
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, potential for more than minimal harm
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, potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident
Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.