Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, potential for more than minimal harm
96 citations on record, 5 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 | 3 | 0 |
| 2025 | 60 | 2 |
| 2024 | 22 | 1 |
| 2023 | 11 | 2 |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, potential for more than minimal harm
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
No actual harm, potential for more than minimal harm
Put firmly secured handrails on each side of hallways.
No actual harm, potential for more than minimal harm
Keep all essential equipment working safely.
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
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, potential for more than minimal harm
Dispose of garbage and refuse properly.
No actual harm, potential for more than minimal harm
Provide or obtain dental services for each resident.
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
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, 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 for the safe, appropriate administration of IV fluids for a resident when needed.
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
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, potential for more than minimal harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, potential for more than minimal harm
Ensure each resident receives an accurate assessment.
No actual harm, potential for more than minimal harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, potential for more than minimal harm
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
No actual harm, potential for more than minimal harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
No actual harm, potential for more than minimal harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, potential for more than minimal harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, potential for more than minimal harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, potential for more than minimal harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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
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, 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
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, potential for more than minimal harm
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, 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 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
Make sure that a working call system is available in each resident's bathroom and bathing area.
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
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.