34 citations on record, 2 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 | 6 | 0 |
| 2024 | 19 | 2 |
| 2023 | 9 | 0 |
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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
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
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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
Keep all essential equipment working safely.
No actual harm, potential for more than minimal harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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
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
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
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 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
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
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
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, potential for more than minimal harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, potential for more than minimal harm
Honor the resident's right to organize and participate in resident/family groups in 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.
Immediate jeopardy to resident health or safety
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
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 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 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
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
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
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, potential for more than minimal harm
Ensure medication error rates are not 5 percent or greater.
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
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
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.