Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, potential for more than minimal harm
81 citations on record, 3 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 | 20 | 1 |
| 2025 | 38 | 2 |
| 2021 | 23 | 0 |
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
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, potential for more than minimal harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, potential for more than minimal harm
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
No actual harm, potential for more than minimal harm
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
No actual harm, potential for more than minimal harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
No actual harm, potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, potential for more than minimal harm
Respond appropriately to all alleged violations.
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
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
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 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, 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
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
No actual harm, potential for more than minimal harm
Observe each nurse aide's job performance and give regular training.
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.
Immediate jeopardy to resident health or safety
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 care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, potential for more than minimal harm
Respond appropriately to all alleged violations.
No actual harm, potential for more than minimal harm
Keep all essential equipment working safely.
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
Provide and implement an infection prevention and control program.
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 or obtain dental services for each resident.
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 each resident’s drug regimen must be free from unnecessary 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 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
Observe each nurse aide's job performance and give regular training.
No actual harm, potential for more than minimal harm
Provide care or services that was trauma informed and/or culturally competent.
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, potential for more than minimal harm
Assist a resident in gaining access to vision and hearing services.
No actual harm, potential for more than minimal harm
Provide activities to meet all resident's needs.
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
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.