Infection Control Deficiencies
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
67 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 | 0 |
| 2025 | 29 | 2 |
| 2024 | 31 | 0 |
| 2023 | 2 | 0 |
Provide and implement an infection prevention and control program.
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 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
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 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
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
No actual harm, minimal potential
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
No actual harm, potential for more than minimal harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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
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 safe, appropriate dialysis care/services for a resident who requires such services.
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
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
Allow residents to self-administer drugs if determined clinically appropriate.
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
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, potential for more than minimal harm
Observe each nurse aide's job performance and give regular training.
No actual harm, potential for more than minimal harm
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
Provide care or services that was trauma informed and/or culturally competent.
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
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
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
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 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
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
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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
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
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
Immediate jeopardy to resident health or safety
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Immediate jeopardy to resident health or safety
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 policies and procedures to prevent abuse, neglect, and theft.
No actual harm, potential for more than minimal harm
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
No actual harm, potential for more than minimal harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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
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
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.