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
48 citations on record, 4 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 |
|---|---|---|
| 2025 | 7 | 3 |
| 2024 | 19 | 1 |
| 2023 | 10 | 0 |
| 2022 | 12 | 0 |
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Immediate jeopardy to resident health or safety
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Immediate jeopardy to resident health or safety
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 safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident
Ensure medication error rates are not 5 percent or greater.
No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, potential for more than minimal harm
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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
Provide and implement an infection prevention and control program.
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
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
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
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, potential for more than minimal harm
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
No actual harm, potential for more than minimal harm
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, 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
Provide safe, appropriate pain management for a resident who requires such services.
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
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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
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
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, potential for more than minimal harm
Keep residents' personal and medical records private and confidential.
No actual harm, potential for more than minimal harm
Reasonably accommodate the needs and preferences of each resident.
No actual harm, potential for more than minimal harm
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
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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
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 safe and appropriate respiratory care for a resident when needed.
No actual harm, potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
No actual harm, potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, potential for more than minimal harm
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.