ElderGrade

Inspection citations at Marymount Manor

51 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.

Reading the scope & severity code

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.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 16 0
2024 17 0
2023 6 3
2022 12 0
D September 9, 2025 Tag F0684 Complaint investigation Corrected Oct 2025

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

C June 13, 2025 Tag F0887 Corrected Jul 2025

Infection Control Deficiencies

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, minimal potential

C June 13, 2025 Tag F0881 Corrected Jul 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, minimal potential

C June 13, 2025 Tag F0732 Corrected Jul 2025

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

C June 13, 2025 Tag F0679 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, minimal potential

C June 13, 2025 Tag F0656 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

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, minimal potential

C June 13, 2025 Tag F0628 Corrected Jul 2025

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, minimal potential

C June 13, 2025 Tag F0584 Corrected Jul 2025

Resident Rights Deficiencies

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, minimal potential

E June 13, 2025 Tag F0883 Corrected Jul 2025

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

E June 13, 2025 Tag F0880 Corrected Jul 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E June 13, 2025 Tag F0761 Corrected Jul 2025

Pharmacy Service Deficiencies

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

E June 13, 2025 Tag F0727 Corrected Jul 2025

Nursing and Physician Services Deficiencies

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

E June 13, 2025 Tag F0700 Corrected Jul 2025

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

E June 13, 2025 Tag F0695 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

E June 13, 2025 Tag F0658 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E June 13, 2025 Tag F0641 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D September 25, 2024 Tag F0626 Complaint investigation Corrected Sep 2024

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

No actual harm, potential for more than minimal harm

D September 25, 2024 Tag F0609 Complaint investigation Corrected Sep 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

D March 28, 2024 Tag F0677 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

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

D March 28, 2024 Tag F0623 Corrected Apr 2024

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, potential for more than minimal harm

D March 28, 2024 Tag F0583 Corrected Apr 2024

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

No actual harm, potential for more than minimal harm

E March 28, 2024 Tag F0761 Corrected Apr 2024

Pharmacy Service Deficiencies

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

E March 28, 2024 Tag F0728 Corrected Apr 2024

Nursing and Physician Services Deficiencies

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

No actual harm, potential for more than minimal harm

E March 28, 2024 Tag F0700 Corrected Apr 2024

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

E March 28, 2024 Tag F0689 Corrected Apr 2024

Quality of Life and Care Deficiencies

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

E March 28, 2024 Tag F0679 Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

E March 28, 2024 Tag F0657 Corrected Apr 2024

Resident Assessment and Care Planning Deficiencies

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

E March 28, 2024 Tag F0656 Corrected Apr 2024

Resident Assessment and Care Planning Deficiencies

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

E March 28, 2024 Tag F0584 Complaint investigation Corrected Apr 2024

Resident Rights Deficiencies

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

E March 28, 2024 Tag F0558 Complaint investigation Corrected Apr 2024

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

F March 28, 2024 Tag F0881 Corrected Apr 2024

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

F March 28, 2024 Tag F0880 Complaint investigation Corrected Apr 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F March 28, 2024 Tag F0812 Corrected Apr 2024

Nutrition and Dietary Deficiencies

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

E December 18, 2023 Tag F0725 Complaint investigation Corrected Jan 2024

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

E December 18, 2023 Tag F0689 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

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

G December 18, 2023 Tag F0697 Complaint investigation Corrected Jan 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Actual harm to a resident

G December 18, 2023 Tag F0686 Complaint investigation Corrected Jan 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

J December 18, 2023 Tag F0684 Complaint investigation Corrected Jan 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Immediate jeopardy to resident health or safety

E September 19, 2023 Tag F0677 Complaint investigation Corrected Oct 2023

Quality of Life and Care Deficiencies

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

C September 30, 2022 Tag F0732 Corrected Nov 2022

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

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.