Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
No actual harm, potential for more than minimal harm
19 citations on record, 0 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 |
|---|---|---|
| 2024 | 8 | 0 |
| 2023 | 1 | 0 |
| 2022 | 10 | 0 |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
No actual harm, potential for more than minimal harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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
Reasonably accommodate the needs and preferences of each resident.
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
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
No actual harm, potential for more than minimal harm
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
No actual harm, potential for more than minimal harm
Honor the resident's right to manage his or her financial affairs.
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 and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, potential for more than minimal harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 medication error rates are not 5 percent or greater.
No actual harm, potential for more than minimal harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.