Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, potential for more than minimal harm
41 citations on record, 15 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 | 17 | 7 |
| 2024 | 9 | 0 |
| 2023 | 10 | 8 |
| 2022 | 5 | 0 |
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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
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
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
Ensure services provided by the nursing facility meet professional standards of quality.
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
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
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
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Immediate jeopardy to resident health or safety
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety
Have a plan that describes the process for conducting QAPI and QAA activities.
Immediate jeopardy to resident health or safety
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.
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
Have a plan that describes the process for conducting QAPI and QAA activities.
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
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 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
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
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
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
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 food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, potential for more than minimal harm
Ensure that residents are free from significant medication errors.
No actual harm, potential for more than minimal harm
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Immediate jeopardy to resident health or safety
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Immediate jeopardy to resident health or safety
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Immediate jeopardy to resident health or safety
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 there is a pest control program to prevent/deal with mice, insects, or other pests.
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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
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
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.