Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maywood Skilled Nursing & Wellness Centre during CMS and state inspections, most recent first.
Ombudsman Contact Information Not Posted: The facility failed to keep the State LTC Ombudsman program’s contact information posted in a visible area for residents. An alert resident with COPD, HTN, and dysphagia stated he did not know where to find the information, and the IPN and DON confirmed it was not posted after being removed during repainting. The facility policy stated the Ombudsman and CDPH contact details were to be posted on the consumer board.
An LVN did not administer a resident’s ordered cholecalciferol and documented it incorrectly on the MAR. For another resident with a change in condition, a UA with C&S order was not properly entered, endorsed, or followed up, so assigned nurses were not aware of the pending lab work. A third resident receiving haloperidol 4 mg BID was not monitored for sedation or other psychotropic side effects, and the MAR did not show the required monitoring.
Failure to submit accurate PBJ staffing data: Surveyors found the facility did not submit quarter one direct care staffing information to CMS, even though the ADM said a third-party company handled quarterly submissions and the data should have been sent. The CPD stated the submission database changed the quarter selection from Q1 to Q2, so Q1 data was submitted under the wrong quarter and the error went unnoticed. The DON stated staffing hours were important for meeting required hours and identifying staffing issues.
Call Light Not Within Reach: A resident with falls, muscle weakness, dysphagia, schizoaffective disorder, COPD, and bilateral knee contractures was observed lying in bed with the call light hanging behind and under the bed, out of reach. A photo confirmed the call light was not accessible, and an LVN stated call lights should always be within reach and verified during routine safety checks; the facility policy stated the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Resident’s Medication Preference: An LVN administered Depakote Sprinkle capsules whole to a resident with epilepsy, bipolar disorder, and schizophrenia even though the order directed the medication to be mixed with applesauce. The LVN stated the resident usually preferred to take the capsules whole, but she did not notify the physician of that preference. The DON stated the physician should have been informed because the order was intended to reduce choking risk.
Exposed Resident Belongings in Room Closets: Three residents with severely impaired cognition had their clothing and personal belongings left visible when all closet doors were missing in their shared room. One resident stated they did not want people seeing their belongings, and the DON acknowledged the missing doors left items exposed and at risk for potential theft. The facility policy called for a safe, clean, comfortable, and homelike environment.
A resident admitted from a GACH had schizophrenia, bipolar disorder, depression, cognitive impairment, and psychotropic medication use, but the PASRR Level 1 screening incorrectly stated the resident did not have a serious mental illness and was not taking psychotropic medication. The MDS nurse and DON stated the screening should have been reviewed for accuracy and that a new PASRR Level 1 should have been submitted so a PASRR Level 2 assessment could be completed.
Delayed Care Planning for Dentures and Sedating Medication: The facility did not timely develop and implement individualized care plans for a resident who was edentulous and refused to wear dentures, another resident whose full dentures were received by social services but not communicated to nursing, and a third resident who was frequently asleep in bed and receiving Haloperidol. Records, observations, and staff interviews showed the residents had identified needs, but care planning was delayed or omitted, including denture-related needs and daytime bedrest concerns.
A resident with epilepsy, bipolar disorder, and schizophrenia had a physician order for Depakote Sprinkle to be mixed with applesauce, but staff observed an LVN giving the capsules whole with water. The LVN stated she knew the resident did not like it mixed with applesauce and did not follow the order. The DON stated the resident’s care plans should have been updated to reflect the resident’s preference to take the medication whole if safe.
Failure to orient a legally blind resident to his meal tray during lunch. The resident had severely impaired vision, needed supervision or touching assistance while eating, and his care plan called for assistance with ADLs, including eating. During observations, he was eating by himself and could not find his spoon, and he stated staff did not orient him to the tray. CNA 2 said she placed the tray but did not give a detailed orientation, and the DON stated the resident should receive coaching when a meal tray is provided.
Medication administration errors were observed involving two residents. One resident received a regular multivitamin instead of the ordered multivitamin-minerals, had cholecalciferol documented as given when it was not administered, and had a Colace refusal inaccurately charted on the MAR. Another resident with epilepsy was given Depakote Sprinkle whole instead of being opened and mixed with applesauce as ordered. The DON and LVNs acknowledged the incorrect administration and documentation.
Improper cleaning of resident dishware and failure to label/store visitor food were observed. Clean water pitchers had sticky residue and old labels, and breakfast bowls had dried food residue. A resident with intact cognition and orders for NAS/CCHO diet had grapes from a family member left at the bedside without a date label, and the DS stated visitor food should be labeled and stored in the refrigerator.
Inaccurate fall risk records and missing denture documentation: The facility documented one resident’s vision status as adequate even though records and staff interviews showed impaired vision, and another resident’s post-fall evaluations were left incomplete with missing contributing factors after two falls. The facility also failed to update a resident’s special needs and belongings records to show upper and lower dentures had been received, and the dentures later could not be located.
Undated oxygen tubing and humidifier bottle. A resident with COPD, respiratory failure, diabetes, and heart failure was receiving O2 via NC, with an order for tubing changes every 7 days. During observation, the tubing and humidifier bottle were not dated, and an RN stated both items should be labeled with a date.
The facility failed to maintain appropriate food temperatures during lunch service, with quesadillas and lasagna found at 120°F and 126°F, below the required 140°F. The dietary staff placed these items away from the stove due to space constraints, leading to inadequate temperatures. The Dietary Supervisor confirmed these temperatures were unacceptable, potentially affecting 112 residents' food intake and posing a risk of unplanned weight loss.
The facility failed to maintain safe food temperatures, with quesadillas and lasagna measuring below the required 140°F. This deficiency affected 112 of 115 medically compromised residents, posing a risk of bacteria growth and foodborne illness. The issue arose due to inadequate space on the stove and steam table, leading to improper food storage.
The facility was found to have improper garbage storage practices, as two trash dumpster lids were not closed completely. This was observed during a survey and confirmed by the Dietary Supervisor and Infection Preventionist Nurse, who both stated that the lids should be closed to prevent flies and maintain infection control. The facility's Administrator acknowledged the lack of a specific policy requiring the lids to be closed, despite existing guidelines for covered food waste disposal.
The facility failed to report abuse allegations involving two residents to the State Agency, ombudsman, and police. One resident reported hurtful comments by a CNA, while another alleged inappropriate touching during care. Despite internal reporting, external agencies were not notified, delaying investigation and potentially exposing other residents to abuse.
Two residents reported abuse by a CNA, but the facility failed to conduct thorough investigations or suspend the CNA, leaving other residents at risk. Despite reports of hurtful comments and inappropriate touching, the facility only reassigned the CNA without further action, violating its abuse reporting policy.
The facility failed to respect the rights and dignity of two residents. One resident did not have a public guardian or IDT meeting to facilitate care, resulting in medical treatments without consent. Another resident's nephrostomy bags were not covered with a dignity bag, contrary to facility policy. These actions demonstrate a lack of adherence to policies ensuring resident rights and dignity.
A facility failed to obtain updated informed consents for psychotropic medications for a resident unable to make medical decisions. Despite severe cognitive impairment, the resident was administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride without consent from a responsible party or public guardian, nor was an IDT convened. The facility's policy required surrogate decision-making, which was not followed, as confirmed by an LVN.
A resident with aphasia in an LTC facility was not provided with a communication device at her bedside, hindering her ability to communicate effectively. Despite having a care plan that included the use of a communication board, the resident relied on gestures and writing, which were not always understood by staff and visitors. The facility's policy to provide adaptive devices for communication was not followed.
Three residents were found on low air loss mattresses (LALM) set incorrectly for their weights, risking the worsening of pressure ulcers. A resident with a resolved Stage III ulcer was on a LALM set for 300 lbs instead of 170 lbs. Another resident with a surgical wound was on a LALM set for 200 lbs instead of 147.8 lbs. A third resident with a Stage II ulcer was on a LALM set for 550 lbs instead of 190.2 lbs. The facility's policy to ensure proper LALM settings was not followed.
The facility failed to adequately monitor and care for a resident with a long-term indwelling urinary catheter, leading to septic shock, and another resident with nephrostomy tubes, risking urinary tract infections. The staff did not follow care plans or physician orders, failing to document and communicate changes in the residents' conditions.
A facility failed to check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for a resident with severe cognitive impairment and multiple medical conditions. The care plan required checking these parameters every shift, but an LVN started the tube feeding without doing so, acknowledging the oversight. The DON highlighted the importance of these checks to prevent complications, as outlined in the facility's policy.
Two residents in the facility were found with unlabeled nebulizer masks, which lacked the resident's name and date of opening, posing an infection risk. Both residents had significant medical conditions, including COPD and dementia, and required assistance with daily activities. The facility's policy required masks to be changed and labeled every seven days, but this was not followed, as confirmed by staff interviews.
A resident with a history of UTI, sepsis, and diabetes reported feeling uncomfortable during a bed bath, alleging inappropriate touching by a CNA. Despite the resident's moderate cognitive impairment, he was capable of making decisions. The LVN reassigned the CNA but did not notify the physician, contrary to facility policy. The RN and DON acknowledged the physician should have been informed to assess and implement necessary interventions.
The facility failed to create care plans for two residents after allegations of inappropriate behavior by a CNA. One resident reported hurtful comments affecting her emotional state, while another alleged inappropriate touching during a bed bath. Despite investigations and reassignment of the CNA, care plans were not developed, contrary to facility policy.
A resident with dementia and known behavioral issues, including biting and elopement risk, did not have a comprehensive care plan in place. This led to an incident where the resident wandered into another resident's room, resulting in an altercation. The facility's policies on care planning and risk management were not followed.
A resident with dementia and behavioral issues was inadequately supervised, leading to an altercation with another resident. Despite care plans requiring frequent checks, staff were too busy to monitor the resident every 15 minutes, allowing them to wander into another resident's room and cause an incident.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman program contact information was posted in a visible area for residents. During observation of the front lobby and the walls throughout the facility, no Ombudsman contact information was posted. The Infection Prevention Nurse stated the information was usually posted in the front lobby but was not posted at the time because it had been taken down when the walls were recently repainted. The nurse also stated the information should be posted in a visible place for residents so they could report concerns or make complaints to the Ombudsman. Resident 52, who was admitted and later readmitted to the facility, had diagnoses including COPD, HTN, and dysphagia. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS described him as cognitively intact and needing staff supervision for eating and toileting, with partial assistance for bathing and personal hygiene. During interview, Resident 52 stated he did not know where to find the Ombudsman’s contact information in the facility. The DON stated the Ombudsman information was usually posted in the front lobby but had been removed during repainting, and the facility policy stated that addresses and telephone numbers for the local Long Term Care Ombudsman’s office and the California Department of Public Health were posted on the facility consumer board.
Medication administration, lab order follow-up, and psychotropic monitoring failures
Penalty
Summary
The facility failed to ensure a resident received cholecalciferol as ordered when an LVN did not clarify the medication during administration and then documented it as given on the MAR even though it was not administered. The resident had diagnoses including protein-calorie malnutrition, generalized muscle weakness, and generalized osteoarthritis, and was cognitively intact with capacity to understand and make decisions. During the observed medication pass, the LVN prepared and administered other medications but did not give the cholecalciferol. She later stated she was confused by the order and the house supply medications, did not want to risk giving the wrong medication, and documented incorrectly. The DON stated the medication should have been clarified during the medication administration timeframe and that the resident did not receive the daily dose. The facility also failed to carry out a physician order for a UA with C&S for a resident with diabetes, Alzheimer’s disease, muscle weakness, and neuromuscular dysfunction of the bladder. The resident had a change in condition with getting up unassisted, yelling, and combative and aggressive behaviors, and the physician ordered the urine testing. The order was not properly entered into the physician orders, was not visible to assigned nurses, and there was no documentation showing endorsement, attempts to obtain the specimen, or follow-up. RN staff stated they were not made aware of the pending order because it was not endorsed or documented in a way that allowed follow-up, and the DON stated the order was not properly inputted and should have had an end date to ensure awareness. The facility further failed to monitor a resident receiving haloperidol 4 mg twice daily for sedation and related side effects. The resident had COPD, muscle weakness, dysphagia, and dementia, and was severely cognitively impaired and dependent on staff for toileting, bathing, and dressing. The care plan and psychotropic risk form identified sedation as a risk and indicated monitoring for adverse reactions such as sedation and dizziness, but the MAR did not show monitoring for sedation. During observation, the resident was found asleep in bed and did not respond to verbal stimuli until repeated attempts and tactile stimulation, including a sternal rub. The DON stated monitoring for sedation was important due to the risk for falls or excessive sedation and to allow the physician to be notified if medication adjustments were needed.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to ensure direct care staffing information was submitted to CMS based on payroll and other verifiable and auditable data. During review of the PBJ Staffing Data Report dated 3/19/2026, surveyors found the facility had not submitted data for quarter one (10/1/2025-12/31/2025). In a concurrent interview and record review with the ADM, the CMS Submission Report dated 2/13/2026 showed direct care staffing information was submitted for quarter two (1/1/2026-3/31/2026) on 2/13/2026. The ADM stated the facility used a third-party company to submit the quarterly staffing information and acknowledged that quarter one data should have been submitted. During interviews, the CPD stated the database used to submit staffing information changed the selection for submission from quarter one to quarter two, and that quarter one's data had been submitted but the error in quarter selection went unnoticed. The CPD stated this error caused the facility to be triggered for failing to submit data for quarter one. The DON stated submitting direct care staffing hours was important because it ensured the facility met required hours and helped identify staffing issues, and that staffing hours helped indicate the level of care being provided to residents. The facility policy titled Electronic Staffing Data Submission Payroll-Based Journal stated direct care staffing and census data would be collected quarterly and was required to be timely and accurate.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was readily accessible and within reach for one sampled resident, Resident 112. Resident 112 was admitted with diagnoses including falls, muscle weakness, dysphagia, schizoaffective disorder, COPD, and contractures of both knees. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated mildly impaired cognitive skills for daily decision making and moderate assistance needed for ADLs. During an observation at the resident’s bedside, Resident 112 was lying in bed and the call light was hanging behind and under the bed, out of reach. A concurrent review of a photo taken at the time of the observation confirmed the call light was behind the bed and not accessible. LVN 1 stated that call lights should always be within reach, including after care, repositioning, toileting, and transfers, and that staff were expected to verify accessibility as part of routine safety checks. The facility policy titled Communication- Call System stated that the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Resident’s Medication Preference
Penalty
Summary
The facility failed to notify Resident 91’s physician of the resident’s preference to take Depakote Sprinkle capsules whole. Resident 91 was admitted and readmitted to the facility with diagnoses including epilepsy, bipolar disorder, and schizophrenia. The resident’s MDS indicated cognition was intact and that the resident required supervision or touching assistance with several activities of daily living. The resident’s H&P stated the resident had the capacity to understand and make decisions, and the care plan for risk of aspiration/choking directed staff to crush medications and mix with applesauce if indicated. During observation, LVN 5 prepared Resident 91’s routine medications and administered the Depakote Sprinkle capsules whole along with the resident’s other medications. During interview, LVN 5 stated the Depakote Sprinkle was supposed to be administered with applesauce, that the capsule should be opened and the beads poured over applesauce, and that she did not follow the physician’s order. LVN 5 also stated the resident’s usual preference was to take the capsules whole, but she should still have asked the resident before administering them and did not notify the physician of the preference. The DON stated licensed nurses were responsible for following medication administration instructions and that the physician should have been notified because the order was to mix the medication with applesauce to reduce the risk of choking.
Exposed Resident Belongings in Room Closets
Penalty
Summary
The facility failed to ensure residents' clothing and personal belongings were protected from view and potential loss when closet doors were left uncovered without doors or adequate protective measures for three sampled residents. Resident 11 was admitted and readmitted to the facility with diagnoses including pneumonia, COPD, Alzheimer's disease, and muscle weakness. The MDS dated 3/4/2026 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, bathing, toileting, and dressing. Resident 25 was admitted and readmitted with diagnoses including diabetes, Alzheimer's, muscle weakness, and neuromuscular dysfunction of the bladder, and the MDS indicated severely impaired cognitive skills and need for moderate assistance with oral hygiene, toileting, and dressing. Resident 116 was admitted and readmitted with diagnoses including COPD, muscle weakness, and dysphagia, and the MDS indicated severely impaired cognitive skills and dependence on staff for oral hygiene, toileting, bathing, and dressing. During observations in Room A, all three closet doors were missing, leaving the clothing and personal belongings of Residents 11, 25, and 116 exposed. Resident 116 stated that the closets were not supposed to be like that and that they did not want people seeing their belongings. The DON stated that the absence of closet doors made the residents' personal belongings exposed and at risk for potential theft, and stated the facility was aware of the issue. The facility policy on Resident Rooms and Environment stated that the facility was to ensure a safe, clean, comfortable, and homelike environment and to provide a pleasant environment that emphasized residents' comfort, independence, and personal needs and preferences.
Incorrect PASRR Screening for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the correct PASRR Level 1 screening was received and reviewed for a resident admitted from a general acute care hospital. The resident had diagnoses of schizophrenia and major depressive disorder on the admission record, and the MDS also identified bipolar disorder, moderate cognitive impairment, and use of antipsychotic and antidepressant medications. The resident’s H&P indicated the resident could make needs known but could not make medical decisions, and the hospital H&P listed bipolar disorder and schizophrenia. The hospital discharge reconciliation directed continuation of aripiprazole, fluoxetine, and mirtazapine after discharge. The facility’s physician orders also included aripiprazole for schizophrenia with aggressive behavior, fluoxetine for depression with refusal to participate in previously enjoyed activity, and later mirtazapine for depression with poor oral intake. A psychiatric evaluation documented diagnoses of schizophrenia, bipolar disorder, and depression with psychotropic medication use. During interview and record review, the facility’s MDS nurse stated the PASRR Level 1 from the hospital was reviewed on admission to determine whether a Level 2 assessment was needed, but the resident’s PASRR Level 1 incorrectly indicated the resident did not have a serious mental illness and was not taking psychotropic medication. The MDS nurse stated the screening was not accurate because the resident had schizophrenia, bipolar disorder, and psychotropic medication use, and that a new PASRR Level 1 should have been submitted so a Level 2 assessment could be completed. The DON stated the PASRR Level 1 should have been reviewed by nursing and admissions staff for accuracy and that the inaccurate screening should have been identified on admission.
Delayed Care Planning for Dentures and Sedating Medication
Penalty
Summary
The facility failed to develop and implement comprehensive care plans in a timely manner for three residents who had specific care needs related to dentures and use of Haloperidol. The report states that the deficient practice involved Resident 22, Resident 28, and Resident 4, and that the care plans were not developed when the residents’ conditions and needs were identified through assessment, observation, and record review. Resident 22 was admitted and later readmitted to the facility with diagnoses including COPD, diabetes mellitus, and dementia. The MDS indicated the resident was moderately impaired in daily decision-making, dependent on staff for multiple ADLs, and edentulous. Dental notes showed dentures were delivered to the facility, and the resident was observed without natural teeth and stated she had dentures but did not know where they were. Staff interviews confirmed the resident refused to wear her dentures. The MDS nurse stated the care plan for the resident’s edentulous status was developed only after the annual MDS was completed, and that a care plan addressing refusal to wear dentures should also have been developed sooner. Resident 28 was admitted with diagnoses including COPD, anemia, muscle weakness, GERD, and diabetes. The resident’s H&P stated she could make needs known but could not make medical decisions, and the MDS showed mild impairment in daily decision-making and need for supervision with ADLs. A dental evaluation report showed the facility received the resident’s full upper and lower dentures, and the resident stated she needed her dentures to eat. The SSD and DON stated the dentures were received by social services, but nursing was not informed, and the dentures were omitted from the special needs list and belongings record. The DON stated the resident needed an individualized care plan for denture care, including cleaning, storage, fit monitoring, and assessment for discomfort or oral breakdown, and that this did not occur because of a communication breakdown. Resident 4 was admitted and readmitted with diagnoses including COPD, muscle weakness, dysphagia, and dementia. The MDS showed severe impairment in daily decision-making, dependence on staff for toileting, bathing, and dressing, and the H&P stated the resident lacked capacity to understand and make decisions. A physician order directed Haloperidol 4 mg by mouth twice daily. Observations showed the resident asleep in bed, slow to respond to verbal prompts, and on another occasion unresponsive to verbal and tactile stimulation until a sternal rub was performed. LVN 6 stated the resident had been napping extensively and keeping his eyes closed for approximately one to two months before the care plan was initiated, and that the care plan should have been started sooner.
Care Plan Not Revised to Reflect Resident’s Medication Preference
Penalty
Summary
The facility failed to revise one sampled resident’s care plan to reflect the resident’s preference for taking Depakote Sprinkle capsules whole. Resident 91 was admitted and readmitted to the facility with diagnoses including epilepsy, bipolar disorder, and schizophrenia. The resident’s MDS dated 2/16/2026 indicated cognition was intact, and the H&P dated 11/11/2025 stated the resident had the capacity to understand and make decisions. A physician order dated 11/9/2025 directed Depakote Sprinkle 500 mg by mouth twice a day for epilepsy and to mix it with applesauce. Resident 91’s care plan for aspiration/choking, initiated 11/10/2025, directed staff to crush medications and mix with applesauce if indicated, and the seizure-related care plan directed staff to administer Depakote Sprinkle 500 mg by mouth twice a day. During observation on 3/24/2026, an LVN prepared and administered the resident’s medications, keeping the capsules whole and giving them with water. During interview, the LVN stated she did not follow the physician’s order and said she knew the resident did not like to take it mixed with applesauce. The DON stated the resident had the right to take medications however preferred as long as it was safe, and that the care plans should have been updated to reflect the resident’s preference to take Depakote Sprinkle capsules whole if there were no safety concerns.
Failure to Orient a Legally Blind Resident to Meal Tray
Penalty
Summary
The facility failed to ensure that Resident 94, who was legally blind and had severely impaired vision, was oriented to his meal tray during lunch. Resident 94's admission record showed diagnoses including legal blindness, COPD, muscle weakness, and hypertension. His MDS indicated he needed supervision or touching assistance while eating, and his care plan stated that he was legally blind and needed assistance with activities of daily living, including eating, to maintain a hazard free and safe environment. During a concurrent observation and interview on 3/23/2026 at 12:24 p.m., Resident 94 was sitting on his bed with his lunch tray in front of him and was eating by himself. He stated he could not find his spoon on the meal tray and that staff did not orient him to the tray. During another observation on 3/24/2026 at 12:20 p.m., he was again eating by himself with no utensil in his hand and could not find his spoon on the tray. CNA 2 stated she placed the tray on the table but did not provide a detailed orientation of the meal tray, and the DON stated that Resident 94 should receive coaching when a meal tray is provided so he knows where each item is located.
Medication Administration Errors and Inaccurate Documentation
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication administration observation involving two residents. Surveyors identified four medication errors out of 27 opportunities, resulting in a 14.81% error rate. The errors involved one resident receiving a multivitamin instead of the ordered multivitamin-minerals, cholecalciferol being documented as given when it was not administered, and Colace refusal being inaccurately documented on the MAR. One resident had diagnoses including protein-calorie malnutrition, generalized muscle weakness, and generalized osteoarthritis. Her MDS indicated intact cognition and that she required supervision or touching assistance with several activities of daily living. Her physician orders included cholecalciferol 1000 units daily, Colace 100 mg daily with instructions to hold for loose stools, and multivitamin-minerals daily. During observation, an LVN prepared and administered medications but gave a regular multivitamin instead of the ordered multivitamin-minerals and did not prepare the cholecalciferol capsule. The LVN later stated she administered the wrong multivitamin and that the cholecalciferol was not given, although it was documented on the MAR as administered. The same resident refused Colace during the observed medication pass, but the MAR was documented as if the medication had been given. The DON stated the refusal should have been accurately documented because it was needed to track bowel movements. Another resident had diagnoses including epilepsy, bipolar disorder, and schizophrenia, with intact cognition and a care plan directing that medications be crushed and mixed with applesauce if indicated. During observation, an LVN removed Depakote Sprinkle capsules from the blister pack and divided them into medication cups, then administered them whole rather than opening the capsules and mixing the beads with applesauce as ordered. The LVN stated she did not follow the physician’s order and acknowledged the medication was supposed to be administered with applesauce to reduce the risk of choking.
Improper Cleaning of Dishware and Unlabeled Visitor Food
Penalty
Summary
The facility failed to ensure resident-use dining equipment was properly cleaned and sanitized. During a concurrent observation and interview in the kitchen, six water pitchers labeled as clean were observed on the clean storage rack with sticky residue and previously dated labels dated 3/21/2026 and 3/22/2026 on the lids. The staff member present stated the residue showed the pitchers had not been thoroughly cleaned before being placed in clean storage, and that labels should have been removed before washing. A dishwasher stated that dining equipment must be inspected after removal from the dishwasher and any items with residual food or debris must be rewashed and sanitized before being placed in clean storage. During another observation, multiple breakfast bowls were seen with dried food residue remaining on their surfaces. The Dietary Supervisor stated that all resident-use dishware, including bowls and water pitchers, must be thoroughly washed, rinsed, and sanitized before reuse, and that kitchen staff should report dirty dishware so proper washing can occur. The supervisor stated the observed condition did not meet facility expectations for safe food handling and sanitation practices. The facility policy titled Dietary Assistant/Dishwasher indicated maintaining a safe and sanitary work environment. The facility also failed to properly label and store food brought in from outside for a resident with type 2 diabetes mellitus, COPD, and major depressive disorder. The resident’s record showed intact cognition, capacity to make decisions, and an order for a NAS and CCHO diet. An opened bag of green grapes was observed on the resident’s nightstand and later a cup of grapes was observed on the bedside table; neither was labeled with the date brought into the facility. The resident stated the grapes were brought by a family member and had been at the bedside for about two days before being placed in the cup. The Dietary Supervisor stated food brought in by visitors had to be labeled with the resident’s name and date received, and that the grapes should have been stored in the refrigerator. The facility policy for food brought in by visitors required food to be labeled with the resident’s name and date received and stored in the designated refrigerator.
Inaccurate fall risk records and missing denture documentation
Penalty
Summary
The facility failed to keep resident records accurate for fall risk and resident property documentation. For Resident 105, the admission record showed diagnoses including COPD, diabetes mellitus, and schizophrenia, and the H&P stated the resident had capacity to understand and make decisions. However, the MDS dated 12/16/2025 indicated moderate cognitive impairment and moderately impaired vision. During review of the Fall Risk Evaluation dated 3/18/2026, the vision status was documented as adequate even though LVN 2 stated the resident was visually impaired and required orientation to objects in the environment. RN 1 also reviewed the ophthalmology note dated 3/3/2026, which indicated the resident was blind in the right eye, and stated the fall risk evaluation was inaccurate because it should have reflected poor vision instead of adequate. For Resident 82, the admission record listed diagnoses including history of falling, diabetes, muscle weakness, and hypertension. The MDS indicated a history of fall and a history of fracture prior to admission. Fall Risk Evaluations dated 1/20/2026 and 2/28/2026 both identified the resident as high risk for falls. The post-fall evaluation dated 2/28/2026 did not indicate the contributing factors for the fall, and the post-fall evaluation dated 3/5/2026 also did not include all contributing factors. LVN 1 stated she completed the post-fall evaluation for the 3/5/2026 fall and acknowledged that several contributing factors were left blank and should have been documented. The DON stated the resident had two falls and that the post-fall evaluation needed to be fully completed so all factors contributing to the falls could be identified. For Resident 28, the admission record listed diagnoses including COPD, anemia, muscle weakness, GERD, and diabetes. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated mildly impaired cognitive skills for daily decision making and supervision needed for ADLs. During observation and interview, Resident 28 stated she wore upper and lower dentures and needed them to eat, but said they had gone missing. The dental evaluation report dated 12/30/2025 showed the resident received full upper and lower dentures, yet the List of Residents with Special Needs did not identify the resident as having dentures. The SSD confirmed the list was not updated after the dentures were received, and the resident's belongings list dated 10/17/2025 was also not updated to reflect the dentures. The DON confirmed the belongings list was not updated and stated the omission reflected a breakdown in facility policy and procedure.
Undated oxygen tubing and humidifier bottle
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure that Resident 55’s nasal cannula oxygen tubing and humidifier bottle were labeled with a date. Resident 55 was a [AGE]-year-old female admitted on [DATE] with diagnoses including COPD, respiratory failure, diabetes, and heart failure. Her MDS dated 2/27/2026 indicated she was on oxygen therapy, and a physician’s order dated 2/20/2026 directed oxygen at 2 liters per minute via nasal cannula as needed and that the oxygen tubing be changed every 7 days. During an observation on 3/23/2026 at 11:18 a.m., Resident 55 was lying on her bed wearing her nasal cannula, and the oxygen tubing and humidifier bottle did not have any dates on them. During a concurrent observation and interview on 3/24/2026 at 10:30 a.m., RN 1 observed that both items were still not dated and stated they should be labeled with a date. RN 1 also stated the oxygen tubing must be changed every 7 days. The facility’s policy titled Oxygen Therapy, dated 10/31/2025, indicated oxygen tubing should be changed at least every 7 days and labeled with the date of change.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to maintain appropriate food temperatures during lunch service, as observed on December 17, 2024. During the tray line service, quesadillas and lasagna were found to be at temperatures of 120°F and 126°F, respectively, which are below the facility's required temperature of greater than 140°F for hot foods. The dietary staff placed these food items on a shelf away from the stove and steam table due to a lack of space, leading to the inadequate temperatures. The Dietary Supervisor confirmed that these temperatures were unacceptable and acknowledged that the food would not be palatable for residents, potentially affecting their food intake. The facility's Policy and Procedure on food temperatures, revised on July 1, 2024, was reviewed and indicated that hot food should be maintained above 140°F. However, there was no policy addressing food palatability or menu planning, which the Dietary Supervisor noted should be in place if there were concerns. The deficient practice had the potential to affect 112 of 115 residents who received food from the kitchen, posing a risk of unplanned weight loss due to poor food intake.
Deficient Food Temperature Control in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Specifically, the temperatures of quesadillas and lasagna were found to be below the required safe temperature of 140 degrees Fahrenheit. The quesadillas measured 120 degrees Fahrenheit, and the lasagna measured 126 degrees Fahrenheit. These food items were placed on a shelf away from the stove and steam table due to a lack of space, which contributed to the inadequate temperatures. The dietary staff, including Cook 1, acknowledged the temperature readings and the Dietary Supervisor confirmed that these temperatures were unacceptable according to the facility's policy. The deficiency had the potential to affect 112 of 115 medically compromised residents who received food from the kitchen. The Infection Preventionist Nurse indicated that hot food below 140 degrees Fahrenheit could lead to bacteria growth, potentially causing foodborne illness. The quesadillas were intended for residents on regular and mechanical soft diets, while the lasagna was for those on a liquid diet. The failure to maintain appropriate food temperatures posed a risk of cross-contamination and foodborne illness among the residents.
Improper Garbage Storage Practices
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary manner, as observed during a survey. Two trash dumpster lids were not closed completely, which was confirmed during an observation and interview with the Dietary Supervisor (DS). The DS acknowledged that the lids should be closed to prevent flies, which can transport bacteria and potentially cause illness among residents. The Infection Preventionist Nurse (IPN) also confirmed that the lids should be closed for infection control purposes. The facility's Administrator (ADM) admitted that there was no existing policy requiring the lids to be closed, although the facility's policy on garbage and trash can use indicated that food waste should be placed in covered containers.
Failure to Report Abuse Allegations to Authorities
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the appropriate authorities, including the State Agency, ombudsman, and police department. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA). Despite the report, the Registered Nurse (RN) involved did not notify the external agencies, believing that informing the Director of Nursing (DON) was sufficient. The Director of Staff Development (DSD) confirmed that the CNA had not been assigned to Resident 88 for over a month, but the lack of external reporting delayed further investigation. In a separate incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable with the care provided by the same CNA during a bed bath. The resident alleged inappropriate touching, which was communicated to a Licensed Vocational Nurse (LVN) and the DSD. Although the CNA assignment was changed to ensure the resident's comfort, the allegations were not reported to the necessary external agencies. The LVN assumed that reporting to the DSD would suffice, but the DSD acknowledged that the allegations should have been reported due to the nature of the claims. Interviews with facility staff, including the DON and Administrator, revealed a misunderstanding of the reporting responsibilities. The facility's policy required that all abuse allegations, regardless of perceived validity, be reported to the Administrator and external agencies within two hours. The failure to adhere to this policy resulted in a delay of an onsite inspection by the State Agency and potentially exposed other residents to ongoing abuse.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, which led to a deficiency in protecting residents from potential abuse. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA 2). Despite the report, the facility did not conduct a thorough investigation, as CNA 2 was not suspended, and no further actions were taken after confirming that CNA 2 had not been assigned to Resident 88 for over a month. In another incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath provided by CNA 2. The resident alleged inappropriate touching, which was reported to a Licensed Vocational Nurse (LVN 3) and the Director of Staff Development (DSD). However, the facility only changed the CNA assignment without conducting a thorough investigation or suspending CNA 2, which left other residents potentially vulnerable to similar incidents. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the facility's policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but these steps were not followed. The facility's failure to adhere to its policy and procedure for abuse reporting and investigation resulted in a lack of protection for residents and a deficiency in addressing the allegations appropriately.
Failure to Ensure Resident Rights and Dignity
Penalty
Summary
The facility failed to respect the rights and provide dignity to two residents, Resident 75 and Resident 95. For Resident 75, the facility did not obtain a public guardian or conduct an interdisciplinary team (IDT) meeting to facilitate the care and medical treatments. Resident 75 was admitted with diagnoses including schizophrenia disorder, depressive disorder, and anxiety, and was found to have severely impaired cognitive skills for daily decision-making. Despite this, there was no documentation indicating efforts to find a surrogate decision-maker or apply for public guardianship, resulting in medical treatments and antipsychotics being administered without consent from an appointed decision-maker. For Resident 95, the facility failed to follow its policy and procedure regarding catheter care by not providing a dignity bag for the resident's nephrostomy bags. Resident 95, who had chronic kidney disease and other related conditions, was observed with nephrostomy bags lying uncovered on the bed, which was against the facility's policy. The Licensed Vocational Nurse (LVN) acknowledged the inappropriate handling of the nephrostomy bags and the lack of documentation regarding any refusal of a dignity bag by Resident 95. The Treatment Nurse (TN) later provided education to Resident 95 about the importance of using dignity bags, but initially, there was no documentation or care plan addressing the issue. These deficiencies highlight the facility's failure to ensure the rights and dignity of its residents, as evidenced by the lack of appropriate decision-making support for Resident 75 and the failure to maintain dignity for Resident 95 by not covering the nephrostomy bags. The facility's policies and procedures were not adequately followed, leading to these oversights in resident care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain updated informed consents for the administration of psychotropic medications to Resident 75, who was unable to make medical decisions. Resident 75 was admitted with diagnoses including schizophrenia, depressive disorder, and anxiety, and was assessed as having severely impaired cognitive skills for daily decision-making. Despite this, the facility administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride to Resident 75 without obtaining consent from a responsible party or public guardian, nor did they convene an interdisciplinary team to make medical decisions on behalf of the resident. The facility's policy required that if a resident lacked capacity to provide informed consent, a surrogate decision-maker should be involved, or an interdisciplinary team should be convened if no surrogate was available. However, the facility did not follow this policy, as evidenced by the lack of documentation for obtaining consent from a responsible party or public guardian. This oversight was confirmed during an interview with LVN 4, who acknowledged the importance of obtaining informed consent and the facility's failure to act promptly in securing a public guardian or conducting an IDT meeting for Resident 75.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication device at the bedside for a resident with aphasia, which hindered the resident's ability to communicate effectively. The resident, who had multiple diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, schizophrenia, paraplegia, dysphasia, and aphasia, was observed without a communication board or device in her room. Despite being alert and oriented, the resident was unable to orally communicate and relied on gestures and writing to express her needs. However, her handwriting was not legible, and not all staff and visitors were aware of her communication methods. The resident's care plan, which aimed to improve her communication abilities, included interventions such as allowing time to talk, using a communication board, and providing a pencil and paper. However, these interventions were not fully implemented, as evidenced by the absence of a communication board at the resident's bedside. Interviews with staff revealed that not everyone was aware of the resident's communication methods, and there was a lack of signage to inform visitors. The facility's policy required staff to provide adaptive devices to enable effective communication, but this was not adhered to in the resident's case.
Failure to Properly Set Low Air Loss Mattresses for Residents
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the formation and worsening of pressure ulcers for three residents. Resident 15 was observed lying on a low air loss mattress (LALM) set for a weight of 300 pounds, despite weighing 170 pounds. The resident had a history of chronic obstructive pulmonary disease, generalized muscle weakness, a resolved Stage III pressure ulcer, and schizophrenia. The care plan for Resident 15 indicated the use of a LALM for skin maintenance and wound management, with orders to monitor the settings every shift. However, the LALM was not set correctly, potentially compromising the resident's skin integrity. Resident 94 was also found lying on a LALM set for 200 pounds, while the resident's actual weight was 147.8 pounds. The resident had diagnoses of COPD, malnutrition, generalized muscle weakness, diabetes mellitus, and anemia, with a significant surgical wound on the lower back extending to the buttocks and thighs. The resident's care plan included the use of a LALM for wound management, with instructions to verify its functioning every shift. The incorrect setting of the LALM could have affected the healing of the surgical wound and increased the risk of pressure injuries. Similarly, Resident 36 was observed on a LALM set for 550 pounds, although the resident weighed 190.2 pounds. The resident had a Stage II pressure ulcer, generalized muscle weakness, COPD, and obesity. The care plan required the use of a pressure-reducing device for the bed and chair, with orders to check the LALM settings every shift. The incorrect LALM setting could delay the healing process of the existing pressure ulcer. The facility's policy required staff to ensure the air mattress was inflating properly and to check it routinely, which was not adhered to in these cases.
Inadequate Monitoring and Care of Urinary Catheters and Nephrostomy Tubes
Penalty
Summary
The facility failed to provide adequate care for a resident with a long-term indwelling urinary catheter, leading to the development of septic shock. The resident's urinary drainage was not monitored for sediment, abnormal color, or foul odor for six months, as required by the facility's policies and the resident's care plan. Despite a urine analysis indicating a urinary tract infection, a urine culture was not performed, delaying the identification and treatment of the infection. This oversight resulted in the resident being admitted to the intensive care unit with septic shock secondary to a urinary tract infection. Another resident with nephrostomy tubes also received inadequate care, as the nephrostomy bags were not positioned to gravity, and sediment in the tubing was not documented or reported to the physician. The nursing staff failed to monitor the nephrostomy bags for signs of infection, as required by the resident's care plan and physician orders. This lack of monitoring and documentation had the potential to cause avoidable urinary tract infections and delay treatment for the resident. Interviews with facility staff revealed a lack of adherence to care plans and physician orders, as well as a failure to document and communicate changes in the residents' conditions. The Director of Nursing acknowledged the importance of monitoring urine output and nephrostomy care to prevent infections and sepsis. The facility's policy on catheter care emphasized the need for regular assessment of urinary drainage and prompt notification of physicians in case of infection signs, which was not followed in these cases.
Failure to Verify GT Placement and Residuals for a Resident
Penalty
Summary
The facility failed to properly check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for Resident 12, who was dependent on tube feeding due to dysphagia and other medical conditions. Resident 12's medical history included type 2 diabetes mellitus, chronic kidney disease, dysphagia, Alzheimer's disease, and dementia, with severely impaired cognition and a lack of capacity to make decisions. The care plan for Resident 12 required checking the GT placement and GRV every shift, with specific instructions to hold feeding if the residual was above 100 ml. During an observation, Licensed Vocational Nurse (LVN) 5 was seen connecting and starting Resident 12's tube feeding without checking the residuals or GT placement, contrary to the care plan and facility policy. LVN 5 acknowledged the oversight and the importance of checking these parameters to ensure proper digestion and prevent complications. The Director of Nursing (DON) also emphasized the necessity of verifying GT placement to avoid potential issues such as peritonitis. The facility's policy outlined specific steps for verifying GT placement, which were not followed in this instance.
Unlabeled Nebulizer Masks Pose Infection Risk
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, Resident 52 and Resident 310, as observed during a survey. In both cases, the nebulizer masks used by the residents were found to be unlabeled, lacking the resident's name and the date of opening. This oversight was noted during observations conducted on December 16, 2024, at different times in the residents' rooms. The absence of labeling on the nebulizer masks posed a risk of infection, as it was unclear when the masks were last changed or to whom they belonged. Resident 52, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, generalized muscle weakness, schizophrenia, and dementia, was observed to have an unlabeled nebulizer mask at their bedside. The resident's medical records indicated that they required supervision and partial assistance with various activities of daily living. The order summary report for Resident 52 included an order for albuterol sulfate via nebulizer, highlighting the importance of proper labeling and infection control practices. Similarly, Resident 310, who also had diagnoses of COPD, generalized muscle weakness, schizophrenia, and dementia, was found with an unlabeled nebulizer mask. The resident's medical records showed severe cognitive impairment and a need for assistance with daily activities. The facility's policy and procedure for oxygen therapy, which was also applied to nebulizer masks, required that masks be changed every seven days and labeled with the resident's name and date. The failure to adhere to these procedures was confirmed through interviews with the Licensed Vocational Nurse and the Infection Preventionist Nurse, who acknowledged the potential for infection due to the lack of labeling.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician of an abuse allegation made by a resident, identified as Resident 259, against a Certified Nursing Assistant (CNA). Resident 259, who had a history of urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath when CNA 2 allegedly touched him inappropriately. Despite Resident 259's moderate cognitive impairment, he was deemed capable of understanding and making decisions. The incident was reported to a Licensed Vocational Nurse (LVN), who reassigned the CNA but did not notify the physician, believing the issue was resolved. The Registered Nurse (RN) and Director of Nursing (DON) both stated that the physician should have been informed of the abuse allegation to assess and implement necessary interventions for Resident 259. The facility's policy required immediate notification of the attending physician upon receiving allegations of sexual abuse. The failure to notify the physician resulted in a delay in any necessary care for Resident 259, as the physician was unaware of the situation and could not determine if further assessments or interventions were needed.
Failure to Develop Care Plans for Abuse Allegations
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, Resident 88 and Resident 259, after allegations of inappropriate behavior by a Certified Nursing Assistant (CNA 2). For Resident 88, the Responsible Party (RP 1) reported to a Registered Nurse (RN 1) that CNA 2 had said hurtful things to the resident, which affected her emotional state and eating habits. Despite an investigation confirming that CNA 2 had not been assigned to Resident 88 for over a month, no care plan was developed to address the resident's psychosocial needs or to monitor for any further issues. Resident 259 reported feeling uncomfortable during a bed bath given by CNA 2, alleging inappropriate touching. A Licensed Vocational Nurse (LVN 3) reassigned CNA 2 to another resident and did not develop a care plan, believing it was unnecessary since the issue was resolved by the reassignment. However, the Director of Nursing (DON) stated that a care plan should have been developed for any abuse allegation to outline the necessary care based on the specific incident. The facility's policy on Comprehensive Person-Centered Care Planning, revised in August 2023, requires updates to the care plan based on assessed needs. The failure to develop care plans for these incidents indicates a deficiency in adhering to this policy, potentially impacting the residents' physical, mental, and psychosocial well-being.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with known behavioral issues and risk factors. Specifically, the facility did not create a care plan for a resident's known behavior of biting and did not timely implement a care plan for the resident's risk of elopement. This oversight resulted in an incident where the resident wandered into another resident's room, leading to an altercation where the resident hit, attempted to bite, and threw water on the other resident. The resident involved in the incident had a history of dementia, anxiety, and mobility issues, with severely impaired cognitive skills as noted in their Minimum Data Set (MDS). Despite being monitored for biting and identified as an elopement risk, the necessary care plans were not in place. The facility's policies required comprehensive person-centered care planning and specific measures for wandering and elopement risks, which were not adhered to in this case.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to adequately monitor a resident with a known history of wandering, aggression, and other behavioral issues, leading to an incident involving another resident. Resident 1, who has dementia, anxiety, and mobility issues, was not properly supervised despite care plans indicating the need for frequent visual checks and one-to-one supervision. This lack of supervision allowed Resident 1 to wander into Resident 2's room, resulting in an altercation where Resident 1 hit Resident 2, attempted to bite them, and threw water at them. Interviews with staff revealed that Resident 1 was known to enter other residents' rooms and take items, and that staff were often too busy to monitor Resident 1 every 15 minutes as required. The facility's policy required resident checks every two hours, but Resident 1's care plan necessitated more frequent monitoring due to their behavioral risks. The failure to adhere to these monitoring requirements led to the altercation between the two residents, highlighting a deficiency in the facility's supervision and safety protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bell Convalescent Hospital | 1.2 mi | ★★★★★ | 31 | 0 |
| Huntington Park Nursing Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Briarcrest Nursing Center | 2 mi | ★★★★★ | 17 | 0 |
| Greenfield Care Center Of South Gate | 2.1 mi | ★★★★★ | 10 | 0 |
| Los Angeles Comm Hospital | 2.3 mi | ★★★★★ | 15 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.