Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
No actual harm, potential for more than minimal harm
63 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 |
|---|---|---|
| 2025 | 26 | 0 |
| 2024 | 32 | 0 |
| 2023 | 5 | 0 |
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
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
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
Keep all essential equipment working safely.
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
Implement a program that monitors antibiotic use.
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
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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
Observe each nurse aide's job performance and give regular training.
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 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
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
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 and implement an infection prevention and control program.
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
Provide safe and appropriate respiratory care for a resident when needed.
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
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
Respond appropriately to all alleged violations.
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
Ensure that residents are fully informed and understand their health status, care and treatments.
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
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
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 care and assistance to perform activities of daily living for any resident who is unable.
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
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, potential for more than minimal harm
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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 that residents are free from significant medication errors.
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
Provide care or services that was trauma informed and/or culturally competent.
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
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, potential for more than minimal harm
Respond appropriately to all alleged violations.
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.