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
50 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 |
|---|---|---|
| 2026 | 5 | 1 |
| 2025 | 8 | 0 |
| 2024 | 21 | 0 |
| 2023 | 16 | 1 |
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
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident
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
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 get specialized rehabilitative services as required for a resident.
No actual harm, potential for more than minimal harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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
PASARR screening for Mental disorders or Intellectual Disabilities
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
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
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
Provide and implement an infection prevention and control program.
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 services provided by the nursing facility meet professional standards of quality.
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
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, potential for more than minimal harm
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
Ensure that residents are fully informed and understand their health status, care and treatments.
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
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
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
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
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
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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
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
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
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
Post nurse staffing information every day.
No actual harm, minimal potential
Provide enough food/fluids to maintain a resident's health.
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
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.