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 White Blossom Care Center during CMS and state inspections, most recent first.
Unsafe discharge without confirmed destination or HH coordination: A resident with recent brain surgery, weakness, and diabetes was discharged without a complete discharge summary, without a confirmed living arrangement, and without confirmed HH services. The resident’s records showed uncertainty about where she would stay, the HH agency later documented that she was homeless and had no place where services could be provided, and she was later found with stroke symptoms and hospitalized.
A resident with hemiplegia, hemiparesis, DM2, PNA, and sepsis was moved from her room for renovations, but staff did not honor the RP’s request to move her back once the work was done. Interviews showed the room was later occupied by another resident, staff could not assure the resident would return, and the DON stated he had not heard staff ask the resident if she wanted to move back to her prior room, despite the facility’s Resident Rights policy requiring dignity and respect.
Food service sanitation deficiencies were observed in the kitchen and pantry areas when three ice machines had visible residue and buildup, a food prep table was wiped with sanitizer that tested at 50 ppm instead of the posted 200-400 ppm range, and an industrial can opener and its base had residue accumulation. The DM and MS acknowledged the equipment was not clean and that some areas were not being checked or cleaned adequately.
Failure to Educate Families on Safe Handling of Food Brought for Residents: The facility did not follow its policy for foods brought in by family and visitors because it did not educate them on safe food handling practices such as cooling, reheating, holding temperatures, cross-contamination, and hand hygiene. Staff stated they only checked that food texture matched diet orders, and an admission packet handout did not include the detailed safe handling information required by policy. A family member was observed placing soup and pureed food in the refrigerator for a resident.
Unsanitary conditions were observed in the kitchen and related food service areas. Cloth straps used to hold ice chests had yellow and black residue, debris and a dead bug were found around a cabinet and in the walk-in freezer, the air conditioner and chemical room vent were dusty, a section of wall paint was detached, the trayline baseboard was broken and cracked, and the food prep sink drainpipe was connected directly into the wall without an air gap. The DM and MS acknowledged several of the conditions during observation.
Inaccurate dialysis access assessments and incomplete communication records. Staff documented bruit and thrill checks on pre- and post-HCARs for residents with RUC permacaths, even though staff stated those checks were not appropriate for that access type. For three residents receiving HD, DCRs were also left incomplete with blank access site and location fields, and staff acknowledged the records should have been completed through communication with the dialysis center.
Insufficient nursing staffing levels were identified when review of the facility’s staffing data showed multiple instances of CNA DHPPD below 2.4 and total direct care DHPPD below 3.5, mostly on weekends. The staffing coordinator confirmed the facility had no staffing waiver, and the minimum CNA and total DHPPD requirements were not met during the review period.
Kitchen staff lacked competency in sanitizer testing and fortified diet preparation. An aide and the DM did not follow QAC test strip instructions when checking sanitizer used on food contact surfaces, and the DM was unaware the new strips required a 5-second wait before comparing results. In addition, the RD, DM, and a dietary aide did not know or follow fortified diet instructions: fortified trays were marked, but butter was placed as a packet on the tray instead of being added to the food, and gravy was initially placed in a cup on the plate rather than on top of the food.
Infection control practices were not consistently followed when an RN failed to establish a sterile field during a PICC dressing change, respiratory equipment was left exposed and in contact with the floor or bedside table, hand hygiene was missed between care tasks, and resident precautions were not correctly applied for residents with ESBL/MDRO-related orders and history. Staff confirmed the observations, including the lack of proper sterile setup, improper storage of respiratory devices, missed hand hygiene after glove removal, and incorrect or absent precaution signage and EBP placement.
Failure to Maintain Resident Dignity During Meals, Privacy, and Treatment: A nurse fed a resident while standing over the resident’s bed with the door open, care instructions were left openly posted above another resident’s bed, a resident with a drainage bag was left without a covering device in public view, and an RN wrote initials and the date on tape while it was on a resident’s arm during a PICC dressing change. The cited residents had significant medical conditions and cognitive impairment, and staff confirmed several of the dignity and privacy concerns.
A resident with aphasia, dementia, and significant neurologic deficits had a NP order for a UA C&S, and the urine specimen was later obtained by straight catheterization due to incontinence. Surveyors found no documentation that the RP was informed of the ordered lab test or the urine collection procedure, and the RP stated she was not notified of the plan or procedure, only later of the UA result.
An LVN left three oral meds unattended on a resident’s overbed table for self-administration while the resident was lying flat in bed and said he needed to sit up to take them. The LVN later confirmed the meds should not have been left at bedside; the meds were simethicone, gabapentin 800 mg, and aspirin. The DSD stated nurses should stay with residents until all meds are taken, and the facility policy required remaining with the resident during oral med administration.
A resident with dementia and a BIMS score indicating moderate impairment had no care plan developed for the dementia diagnosis, despite facility policy requiring a resident-centered care plan for confirmed dementia. Another resident receiving an RNA knee splinting/bracing program had the splint applied and removed by staff, but no care plan was developed for the program, even though the care plan should describe the services to be furnished and be reviewed with the quarterly MDS.
A resident with Parkinsonism and dysphagia-related hospice care had an SLP eval and treat order, along with a modified diet and thickened liquids, but the order was not carried out. IDT notes showed no therapy because the resident was on hospice, while the ADON was unsure why the SLP eval was not completed. The DOR later identified the order as missed, and the RD confirmed she had recommended the SLP eval due to the diet downgrade but did not follow up.
A resident admitted with ESBL resistance and sepsis received Lasix 40 mg daily for edema, but the order did not identify the specific site of edema and nursing staff did not monitor the edema. The DON confirmed the lack of edema monitoring and stated the Lasix could be a maintenance medication, while the facility policy required medication use to be supported by appropriate assessment and monitoring.
Medication storage was deficient when a medication refrigerator lacked an internal thermometer and its light did not function when opened. An ADON confirmed both issues, and a nurse supervisor said she had recorded a 39 F temp but did not know why the thermometer was no longer inside the unit. In a separate finding, a bottle of Metoclopramide labeled for a resident who had already expired was still in the medication refrigerator nine days later, and the ADON confirmed it should have been removed.
A resident on a Regular diet was served lunch with juice instead of the milk listed on the menu, and the tray ticket showed beverage preferences of coffee and apple. The RD and DM confirmed the menu included milk and that the resident was not offered a nutritionally equivalent substitute when she preferred not to have milk, even though staff asked beverage preferences and later noted snacks were not planned as a milk substitute.
A resident with hemiplegia, hemiparesis, type II DM, and muscle wasting was left in a wheelchair unattended in a hallway after an OT session. The OT reported telling a nurse and a CNA that the resident was in the hallway. An LVN acknowledged being informed and stated the resident remained in the hallway for a short period while the LVN turned away to speak with another resident. A CNA heard a noise, found the resident on the floor with the wheelchair tipped on its side, and the DON reported that another resident had seen the resident’s backpack catch and cause the wheelchair to tip. The resident was later documented as having an abrasion to the left elbow, and facility policy stated residents have a right to a dignified existence.
Staff failed to provide timely assessment, physician notification, and complete documentation for two residents—one who was transferred to the hospital with symptoms of malaise and later diagnosed with sepsis, and another who experienced a fall without proper physician notification or thorough investigation. These actions did not follow facility protocols and were confirmed by staff interviews and record reviews.
Licensed nurses did not accurately complete an elopement and wandering risk assessment for a resident with severe cognitive impairment and multiple diagnoses affecting cognition. The assessment was incomplete and did not reflect the resident's conditions, and no care plan was developed to address elopement or wandering risks, despite facility policy requiring such interventions.
A facility failed to update a Level I PASRR for a resident with a new diagnosis of psychotic disorder. Despite the resident's history of major depressive and mood disorders, and a new diagnosis in June 2023, the PASRR was not updated since March 2022. Interviews with staff confirmed the need for an updated PASRR, as per facility policy.
The facility failed to ensure accurate PASRR Level I screenings for two residents with serious mental disorders. One resident was admitted with schizoaffective disorder and schizophrenia, but the initial screening did not reflect these diagnoses. Another resident had multiple mental health conditions, but only schizophrenia was noted in the screening. The facility did not submit new screenings after the residents stayed over 30 days, as required. Staff interviews revealed a lack of awareness and responsibility for ensuring screening accuracy.
The facility failed to implement proper infection control practices, including leaving bleach containers open, improper glove use by CNAs, and inadequate storage of clean and contaminated items. A resident's nasal cannula was improperly stored, and used meal trays were placed under a water dispenser, all confirmed by staff as against protocol.
A resident received quetiapine fumarate (Seroquel) without adequate indication and monitoring of target behaviors in an LTC facility. The medication was requested by a family member and ordered by a physician without specifying its use or monitoring requirements. The Pharmacy Consultant recommended monitoring, but this was not documented, violating the facility's policy on antipsychotic medication use.
A facility failed to follow infection prevention practices when the door of a Covid-19 isolation room was found open. A resident with acute pulmonary edema and respiratory failure was confirmed Covid-19 positive. Both an LVN and the Infection Preventionist acknowledged the door should have been closed, as per CDC guidelines.
The facility failed to implement proper infection control practices for emergency crash carts. Crash carts B and C contained oropharyngeal airway kits not stored in original packaging and lacked expiration dates. Crash cart A had OPAs with a yellowish substance and no expiration date. Additionally, crash carts B and C had a Yankauer suction tip and nasal cannula without expiration dates, violating facility policy.
The facility failed to conduct thorough investigations and report outcomes for several alleged altercations involving residents. Investigation summaries for altercations between residents did not indicate whether the facility determined if the incidents occurred. The administrator confirmed that the investigations were not thorough or clear, and did not follow the facility's policy for abuse reporting and investigation.
Three residents experienced constipation due to the facility's failure to follow physician orders for bowel management. Despite having orders for interventions like MOM, Bisacodyl suppository, and enemas, these were not administered as prescribed. Staff interviews revealed a lack of adherence to the bowel management protocol, with nurses failing to check and administer necessary medications. The facility's policy required daily review and medication administration, which was not followed.
A Social Service Director failed to document informing a resident's responsible party about a psychologist appointment, preventing the RP from attending. The resident had multiple medical conditions and was not self-responsible, requiring the RP's involvement in treatment decisions.
A resident reported that the rehabilitation staff used a space heater for several months due to a malfunctioning heating unit, while she was not allowed to have one. The space heater was observed in use during a facility tour, and the DON removed it, acknowledging that staff could not use space heaters. The Maintenance Supervisor confirmed the prohibition of space heaters and could not provide maintenance logs for the heating system.
Unsafe discharge without confirmed destination or home health coordination
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge process for one resident when the Notice of Proposed Transfer/Discharge was not provided as soon as practicable before discharge, the resident’s living situation was not adequately assessed and identified, and home health services were not coordinated and confirmed before discharge. The resident had diagnoses including benign neoplasm of cerebral meninges, other specified disorders of the brain, generalized muscle weakness, acute pulmonary insufficiency following thoracic surgery, and type II diabetes mellitus. The resident’s MDS indicated a BIMS score of 15 and need for supervision to partial/moderate assistance with self-care and mobility. The resident had recently returned from an acute care hospital after a left pterional craniotomy for tumor resection. The resident’s discharge planning documentation showed that post-discharge interventions were expected to be needed, including assisted living options and home health options, and the care plan included coordinating home health and/or in-home support services. The NOMNC stated Medicare coverage would end and the discharge date would be the following day, while the resident signed a Notice of Proposed Transfer/Discharge with an effective discharge date. However, the discharge summary and post-care instructions given to the resident did not include the discharge location address or the home health agency name and contact information. The DSS later stated the resident did not specifically say she wanted to go home and was still trying to figure out her home situation because one family member was in Los Angeles and another family member’s availability was uncertain. The home health agency record showed the referral was received on the day of discharge, with an urgent authorization request sent later that day. The agency’s notes documented that the resident was homeless, was living on the street, and did not have a place set up where services could be provided; the agency ultimately marked the referral as a non-admit because it had no way to find or see the resident. The resident was later found by EMS at a fast food place with left facial droop, slurred speech, and left-sided weakness and was taken to the ED, where she was admitted to the ICU for acute stroke, septic shock, acute UTI, and acute respiratory failure. Subsequent hospital documentation identified the resident as homeless and noted she had been living out of her car.
Resident Room Change Did Not Honor Resident Rights
Penalty
Summary
The facility failed to promote Resident 2’s resident rights by not honoring her right to self-determination and dignified treatment during a room change related to renovations. Resident 2’s admission record showed diagnoses including hemiplegia, hemiparesis, type II diabetes mellitus, pneumonia, and sepsis. A Notice of Room or Roommate Change dated 4/6/26 stated she was to be moved from PR CC to PR DD because of renovations. The Social Service note dated 4/9/26 indicated the SSD asked the resident if she would like to stay in her current room or move to a different room, and the DSS later confirmed that a different room was used when Resident 2 was asked if she wanted to move rooms. During interviews, the ADM confirmed PR CC was occupied by another resident and stated Resident 2 was not returned to PR CC to minimize moving residents back and forth. The RP stated she told the AD to move Resident 2 back to PR CC once the work was done, but two days later the room was occupied by another resident. The AD stated the RP was told they could not assure Resident 2 would be moved back to PR CC once the work was done. The DON stated staff would work with the family to find an appropriate room and also stated he had not heard staff ask Resident 2 if she wanted to move back to PR CC. The facility policy on Resident Rights stated residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Food Service Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation during food storage and preparation when three ice machines were observed to be unclean, a kitchen food preparation table was sanitized with a solution that tested below the required strength, and an industrial can opener and its base were not clean. These findings were identified through observation and interview in the kitchen and nursing station pantry areas, and the report states the failures had the potential to increase the risk of food contamination for residents who ate food by mouth. In the kitchen, the ice machine had black residue along the water distribution tube cover and yellow residue on the evaporator plate frame. Black residue wiped off onto a paper towel, and the Maintenance Supervisor stated the ice machine was not considered clean. Thick, dark brown residue was also observed on one drainpipe under the ice machine, and the residue was removed during the observation. The Maintenance Supervisor stated the drainpipes were not checked the last time the ice machine was cleaned and later stated he needed to pay more attention to the drainpipes and clean as needed. At two nursing station pantry rooms, the ice machine dispensers had crusty white, yellow, and pinkish residue around the chutes, and the surfaces were rough to touch. In the kitchen, a Dietary Aide used a cloth soaked with sanitizer to wipe a food preparation table, but the sanitizer tested at 50 ppm, below the 200-400 ppm range posted by the manufacturer. An industrial can opener had orange residue on the blade, and its base had black, brown, and orange residue build-up in the seam where it attached to the table. The Dietary Manager stated the can opener was cleaned once a day, not after each use, and that it did not appear to be getting cleaned every day.
Failure to Educate Families on Safe Handling of Food Brought for Residents
Penalty
Summary
The facility failed to follow its policy and procedure regarding foods brought to residents by family and visitors when it did not educate family members and visitors on safe food handling practices. The undated policy titled "Foods Brought by Family/Visitors" stated that family and visitors are asked to prepare and transport food using safe food handling practices, including safe cooling and reheating processes, holding temperatures, preventing cross-contamination with raw or undercooked foods, and hand hygiene. During observation, a family member placed food in the refrigerator at a nursing station pantry for a resident, and the food included soup and pureed items in reusable plastic containers. An LVN stated that food brought in for residents could be stored in that refrigerator for up to three days. In interviews, the DSD and RD stated that nursing checked whether the texture of food matched resident diet orders, but when asked about education on safe cooling, reheating, holding temperatures, and cross-contamination, the RD stated the facility did not have control over what families did at home. The DON stated nursing was responsible only for what was within its scope of practice and that anything outside that scope would be referred to the RD, who would provide information during family care conferences. The ADM later stated that an admission packet document titled "Outside Food for a Resident" was intended to instruct families on safe food practices, but review of that document showed it did not include the detailed safe handling information required by the facility policy.
Unsanitary kitchen conditions and improper sink drainage
Penalty
Summary
The kitchen and related food service areas were observed to be in unsanitary condition during surveyor observations with the Dietary Manager (DM) and Maintenance Supervisor (MS). Two ice chests used to store ice for weekend use on the units were held by cloth straps that had a significant amount of yellow and black residue on the surfaces. The DM stated the straps looked stained, and the Infection Preventionist stated the straps did not look clean and should have been replaced or cleaned. The DM also stated the ice was used for purposes such as keeping food and beverages cold on medication carts. Additional observations in the kitchen found debris and residue in multiple areas. Behind and around a tall metal filing cabinet near the trayline steam table, there was black debris and a dead bug identified by the DM as a dead cockroach, and more black and brown debris was visible when the cabinet was moved. In the walk-in freezer, debris that appeared to be pieces of food, bits of paper, and brown residue was observed on the floor under the food racks, and the DM stated the racks were not removed when the room was cleaned, leaving residue trapped under and behind them. The air conditioner surface near the trayline table had gray fuzzy residue, and the DM stated it was dusty and should have been cleaned weekly. The kitchen also had structural and plumbing issues. A large section of paint was detached from the wall near the trayline area, and the DM stated it may have been caused by dampness and had not been reported to maintenance. The baseboard around the trayline was broken and cracked with missing chunks and jagged edges. In the chemical room, the vent had gray residue on its surface. Finally, the food preparation sink drainpipe was observed to connect directly into the wall without an air gap, and the MS stated it connected directly to the grease trap. The facility policies and the 2022 Federal Food Code cited in the report required food service areas and equipment to be kept clean, in good repair, and maintained with clean vents and proper plumbing separation.
Inaccurate dialysis access assessments and incomplete dialysis communication records
Penalty
Summary
Provide safe, appropriate dialysis care/services for residents who required hemodialysis. The facility failed to provide dialysis services consistently with professional standards and failed to ensure staff coordinated residents’ care with the dialysis center for three sampled residents receiving hemodialysis. The deficiencies involved inaccurate access site assessment information on pre- and post-hemodialysis communication/assessment records and incomplete dialysis center communication/assessment records. Resident 73 had diagnoses including end stage renal disease and dependence on renal dialysis and was cognitively intact. He stated he received dialysis every Tuesday, Thursday, and Saturday and that his access site was on the right upper chest. Facility staff also identified the access as a right upper chest permacath. Review of the resident’s pre- and post-HCARs showed repeated documentation of bruit and thrill checks for the permacath access, which staff stated was inaccurate because a permacath does not require bruit and thrill assessment. In addition, multiple DCRs for this resident had blank access site and access location fields, and the nursing supervisor stated there were no nurse notes showing staff called the dialysis clinic to complete the DCRs. Resident 42 had diagnoses including generalized muscle weakness and dependence on renal dialysis and had an order to check the dialysis catheter site dressing every shift. Staff identified the resident’s access as a right upper chest two-lumen catheter and stated they do not monitor bruit and thrill for a permacath. However, the resident’s pre-HCARs and post-HCARs documented positive bruit and thrill checks, which the ADON confirmed were incorrect for a permacath. The resident’s DCRs also had blank access site and access location fields, and the ADON stated staff were expected to call the dialysis center when the DCR was incomplete. Resident 99 had diagnoses including resistance to multiple antibiotics and dependence on renal dialysis, with an order to check the dialysis catheter site dressing every shift. Staff identified the access as a right upper chest permacath and stated bruit and thrill should not be checked for that access type, yet the resident’s pre-HCARs and post-HCARs documented positive bruit and thrill checks. The resident’s DCRs were also incomplete with blank access site and access location fields, and the ADON stated staff were expected to call the dialysis center if the DCR was incomplete.
Insufficient Nursing Staffing Levels
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis, especially on weekends, based on the Staffing Data Report submitted to CMS. During a concurrent interview and record review with the staffing coordinator, the documents titled Census and Direct Care Service Hours Per Patient Day from July through December 2025 showed multiple dates when actual CNA DHPPD fell below 2.4, including several weekend dates, and multiple dates when actual total DHPPD fell below 3.5. The staffing coordinator stated that the low staffing from July through December 2025 was mostly on the weekend and that the facility’s required staffing levels were 3.5 DHPPD and 2.4 CNA DHPPD. The staffing coordinator also stated that the facility had no staffing waiver. A review of AFL 21-11 dated March 17, 2021, confirmed that the 3.5 DHPPD staffing requirement, including 2.4 hours per patient day by CNAs, is a minimum requirement for SNFs.
Kitchen Staff Competency Deficiencies in Sanitizer Testing and Fortified Diet Preparation
Penalty
Summary
The facility failed to ensure kitchen staff had appropriate competencies for testing sanitizer strength and for fortifying diets. Two of two kitchen staff, the Dietary Manager and Dietary Aide B, did not follow the manufacturer's instructions for sanitizer test strips when checking the strength of the sanitizer used to clean food contact surfaces in the kitchen. During observation, Dietary Aide B dipped a QAC test strip into the sanitizer and immediately removed it, then stated it was okay to use without comparing the strip to the color chart. The Dietary Manager also tested the sanitizer, compared the strip to the chart, and stated the light yellow color indicated 50 ppm, which he said was not strong enough. During interview and record review, the Dietary Manager stated there was no time frame on the test strip instructions and confirmed he was not aware the new test strips required waiting 5 seconds before comparing the color. He stated the facility had been using the new test strips for about a week and that he thought they had the same instructions as the previous brand. He also stated that for any new products, staff should be trained immediately before use, but he did not provide inservice training before the new strips were used because he was unaware the directions were different. Three staff, the Registered Dietitian, the Dietary Manager, and Dietary Aide A, did not know and/or follow instructions for fortifying diets. During trayline observation, 32 tray tickets were marked fortified, but Dietary Aide A stated butter was added by placing a butter packet on the tray rather than adding butter to the food. The Dietary Manager confirmed the butter packet was placed on the tray. The RD and Dietary Manager were unable to identify a fortified menu during interview, and the diet manual described fortified diets as increasing calorie density by adding items such as butter, margarine, gravy, and sauces to foods. Later, the RD posted a fortified diet schedule in the kitchen, but Dietary Aide A placed gravy in a cup on the plate instead of on top of the food until the RD corrected him. The Dietary Manager stated he was not aware of any inservice on fortified diets before the survey, and the RD confirmed she was not aware of inservices being provided to kitchen staff before that time.
Infection Control Lapses With Sterile Technique, Respiratory Equipment, Hand Hygiene, and Precautions
Penalty
Summary
Infection prevention and control practices were not consistently followed during a PICC line dressing change for a resident with infection and inflammatory reaction due to an internal right hip prosthesis. During observation, the RN did not establish a sterile field on the overbed table. Instead, sterile gloves were placed and opened on the resident’s blanket over the resident’s body, and the PICC dressing kit was also placed and opened on the blanket. In interview, the RN confirmed that a sterile field had not been set up on the overbed table and stated that the table should have been cleaned and covered before equipment was placed there. Respiratory equipment and tubing were observed in an unprotected condition for a resident with respiratory disorders, end stage renal disease, and dependence on renal dialysis. The resident’s nasal cannula attached to portable oxygen at the back of the wheelchair was hanging with the prongs touching the floor. The resident stated the cannula had been touching the floor since the prior night. In a separate observation, the resident’s unlabeled nebulizer mask attached to the machine was exposed and touching the bedside table. The RN confirmed the observations and stated the cannula should not have been hanging and touching the floor, and the nebulizer tubing should have been dated and stored inside a plastic bag. Hand hygiene was not performed between tasks by an RN while providing care to the same resident. After wearing gloves and applying white ointment to the resident’s back, the RN removed the gloves and disposed of them, then opened the medication cart with the key from her pocket without performing hand hygiene. The RN acknowledged that hand hygiene was forgotten after glove removal and before starting a new task. In addition, one resident with an MD order for contact isolation due to ESBL had signage indicating Enhanced Barrier Precautions instead of contact precautions, with no isolation bin outside the room, while another resident with ESBL resistance and sepsis was not placed on EBP despite documentation indicating MDRO precautions were required. The Infection Preventionist confirmed the active contact precaution order for one resident and stated the other resident should have been on EBP based on the clinical record and hospital transfer documentation.
Failure to Maintain Resident Dignity During Meals, Privacy, and Treatment
Penalty
Summary
The facility failed to maintain dignity and respect for Resident 17 during mealtime. Resident 17 had diagnoses including heart failure, dementia, and dysphagia, and her BIMS score was 03. During an observation, RN F was standing at the left side of Resident 17’s bed and feeding her while the resident was positioned lower than the nurse and the room door was open. CNA G later assisted Resident 17 to sit at the edge of the bed and positioned the overbed table with lunch in front of her, and Resident 17 was observed eating independently. RN F confirmed she should have sat beside the resident while feeding her, and the facility’s meal assistance policy stated staff should not stand over a resident while assisting with meals. The facility also failed to protect Resident 167’s confidentiality and dignity by leaving care instructions openly posted above the head of the bed. Resident 167 had diagnoses including cerebral ischemia, a wedge compression fracture of L1, and a benign neoplasm of the meninges, and her BIMS score was 03. Two written instructions were visible from the room entrance door and remained posted during a later observation, including directions about not removing a finger splint and using rash ointment when changing the resident’s diaper. LVN H confirmed the instructions had been posted for a while and stated they should be removed or covered for confidentiality. The facility’s dignity policy stated that signs indicating a resident’s clinical status or care needs are not to be openly posted in the resident’s room. The facility further failed to preserve dignity for Resident 28 and Resident 7 during care. Resident 28, who had a cholecystostomy drain ordered to be measured every shift, was observed sitting in a wheelchair with a drainage bag resting on his legs and no covering bag or privacy device in place; he stated no covering bag was available, later reported the exposed bag caused pain by pulling at the insertion site, and said he felt embarrassed. Resident 7, who had an IV PICC line dressing change order for the right upper arm, was observed after the dressing change with RN N placing tape directly on the resident’s right arm and writing her initials and the date on the tape while it was on the resident’s arm. RN N confirmed this and acknowledged the initials, date, and time should have been written on the tape before it was placed on the resident.
Failure to Notify Responsible Party of UA C&S Order and Urine Collection Procedure
Penalty
Summary
Resident 158, who was admitted with aphasia, dementia, type 2 diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, was observed in her room and was unable to respond verbally but maintained eye contact. Her MDS indicated impaired cognition and that she rarely or never understood. On 2/7/26, the NP ordered a UA C&S, and the licensed nurse carried out the order. The record reviewed by surveyors did not show documentation that the resident’s Responsible Party was informed of the physician-ordered laboratory test or the procedure to obtain the urine specimen. The urine sample was later obtained by straight catheterization on 2/11/26 because the resident was incontinent of urine. Facility staff, including the MDS Coordinator and ADON, could not provide documentation that the Responsible Party had been notified of the urine collection procedure ordered for the UA C&S. Although nursing notes showed the UA results were reviewed and relayed to the MD, and the Responsible Party was notified later about the UA result, the record did not show that the Responsible Party had been informed of the test order or the diagnostic procedure used to collect the specimen. The Responsible Party stated she was not informed of the NP plan, physician order, or urine sample collection and expected to be notified of changes in condition and plan of care.
Medication Left Unattended at Bedside
Penalty
Summary
The facility failed to safely administer medication for one of thirty sampled residents when an LVN left three routine oral medications unattended on Resident 108’s overbed table for self-administration. During a concurrent observation and interview, Resident 108 was lying flat in bed, awake, with three white tablets in a medication cup on the overbed table in front of him. Resident 108 stated he needed to sit up to take his medications. During the same observation, the LVN confirmed he had left the medication because Resident 108 was not ready to take it yet. Resident 108 stated he needed one big pill cut in half and requested more water. The LVN stated he should not have left the medication at bedside and identified the medications as simethicone, gabapentin 800 mg, and aspirin. The DSD stated nurses should not leave medication at a resident’s bedside and should stay with residents until they take their medications. The facility policy for administering oral medications stated to explain the procedure, place medications on the bedside table or tray, assist the resident to a sitting or side lying position, offer water, and remain with the resident until all medications have been taken.
Missing Care Plans for Dementia and RNA Splinting
Penalty
Summary
Resident 105 had diagnoses of alcohol dependence with alcohol induced persisting dementia and non-Alzheimer's dementia, with a BIMS score of 08 on the admission and 5-day MDS assessments. During interview and record review, the social services director confirmed there was no care plan developed for Resident 105's dementia diagnosis, and the MDS coordinator also confirmed she could not find a dementia care plan in the resident's care plan list. The facility's policy stated that for a resident with confirmed dementia, the interdisciplinary team will identify a resident-centered care plan, and that comprehensive person-centered care plans are to be developed within seven days of the required MDS assessment and no more than 21 days after admission. Resident 13 had diagnoses including secondary malignant neoplasm of brain, hemiplegia, hemiparesis, and unspecified cerebrovascular disease affecting the right dominant hand. The quarterly MDS indicated a BIMS score of 06 and five days of RNA program for splint or brace assistance, and the order summary showed an order for an RNA knee splinting or bracing program to the right knee five times per week for 90 days or as tolerated. RNA staff confirmed the right knee splint was applied and removed daily as part of the program, but the director of rehabilitation and the MDS coordinator both confirmed there was no care plan developed for the resident's RNA knee splinting program. The facility policy stated that the comprehensive person-centered care plan describes the services to be furnished and is reviewed and updated at least quarterly with the quarterly MDS assessment.
Missed SLP Evaluation and Treatment Order
Penalty
Summary
The facility failed to provide services according to professional standards for one resident when an SLP evaluation and treatment order was not carried out. The resident was admitted with diagnoses including Parkinsonism and chronic pulmonary edema, and the clinical record showed orders for a mechanical soft chopped diet, nectar-thick liquids, hospice care for dysphagia, and an SLP evaluation and treatment order. The interdisciplinary team conference notes later documented that there was no therapy because the resident was on hospice. During interviews and record review, the ADON stated the IDT should review physician orders, medications, treatments, wounds, and POLST, but she was not sure why the SLP evaluation was not completed. The DOR stated she ran a report and found the SLP evaluation order had been missed, and her note documented that the SLP eval and treat order was missed. The RD confirmed she had recommended the SLP evaluation because of the downgrade in the resident's diet, but she did not follow up to confirm it was completed.
Unmonitored Lasix Order for Edema
Penalty
Summary
Resident 40 was admitted with diagnoses including ESBL resistance and sepsis. The physician ordered Lasix 40 mg by mouth once daily for edema, with instructions to hold if systolic blood pressure was less than 100. The record review showed the nursing staff did not monitor the edema, and the order did not identify the specific site of the edema. During a concurrent interview and record review, the DON stated that monitoring of edema depends on the site of edema, confirmed that Resident 40's Lasix order was for edema without a specific site identified, and confirmed there was no monitoring for edema. The DON also stated the Lasix could be a maintenance medication. The facility policy stated that each resident's medication regimen shall include only those medications necessary to treat existing conditions and that medication use shall be consistent with the individual's condition and responses to treatment, with medications tapered, discontinued, or changed when given without adequate monitoring or without a valid clinical rationale.
Medication Refrigerator Storage and Discontinued Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and maintenance of one of two medication refrigerators. During a concurrent observation and interview in the medication room, there was no thermometer inside the medication refrigerator, and the internal light did not turn on when the door was opened. The Assistant Director of Nursing confirmed both observations and stated that the light should function when the refrigerator is opened and that a thermometer should be kept inside the refrigerator to monitor temperature. A nurse supervisor stated that she had checked the thermometer and recorded a temperature of 39 F on the temperature log, but she did not know why the thermometer was no longer inside the refrigerator afterward. The facility also failed to remove discontinued medication from active stock after a resident expired. Resident 90 had diagnoses including metabolic encephalopathy and expired at 3:00 a.m. on the documented date. During a medication refrigerator inspection, a bottle of Metoclopramide oral solution labeled for Resident 90 was still found inside the medication refrigerator nine days after the resident's death. The Assistant Director of Nursing confirmed that the resident had already expired and that the medication should have been removed from the refrigerator. The facility's policy stated that discontinued, outdated, or deteriorated medications are to be handled through the dispensing pharmacy for return or destruction.
Failure to Provide a Nutritionally Equivalent Substitute for Milk
Penalty
Summary
The facility failed to offer a substitute of similar nutritional value for milk when a resident preferred not to have milk with lunch meals. The resident was observed in the dining room eating the facility-provided lunch with one cup of juice in front of her, and her tray ticket showed a Regular diet with beverages listed as coffee and apple. The menu spreadsheet for the Regular diet listed 8 ounces of milk on the lunch menu, and the Registered Dietitian confirmed the menu was analyzed to meet the DRI. During interviews, the Dietary Manager confirmed milk was on the menu each day for each meal and stated that while residents were asked their beverage preferences, a substitute for milk was not offered if they preferred not to have milk with their meal. The Registered Dietitian and Dietary Manager agreed that coffee and apple juice, which were the resident’s beverage preferences for lunch, did not provide the same nutrients as milk. The Dietary Manager later stated that snacks could be offered between meals or on the meal tray, but those snack choices were not planned as a substitute for milk and could include items such as Jello and fruit.
Resident Left Unattended in Hallway Falls From Wheelchair
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment when a resident with significant physical impairments was left unattended in a hallway and subsequently fell from her wheelchair. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, type II diabetes mellitus, and muscle wasting and atrophy. After an occupational therapy session, the Occupational Therapist placed the resident in her wheelchair outside her room in the hallway and stated he informed a nurse and a CNA that the resident was in the hallway, but he did not recall whether they acknowledged this information. An IDT note documented that therapy had completed a session with the resident approximately three minutes before the incident and left her in the hallway, endorsed to a nurse who was passing medications at that time. According to interviews, LVN A reported being across the hallway when the OT placed the resident in the hallway and stated she acknowledged when the OT told her the resident was back and had been dropped off in the hallway. LVN A further stated the resident remained in the hallway for about two minutes, during which LVN A turned her back to the resident to speak to another resident in another room. CNA B reported being in another resident’s room when she heard a sound like something hitting the floor; upon checking, CNA B found the resident on the floor on her side facing away from the wheelchair, with the wheelchair tipped on its side. The DON stated that another resident, who was later discharged and unavailable for interview, had witnessed the incident and reported that the resident’s backpack hanging on the back of the wheelchair became caught, causing the wheelchair to tip. Nurse’s notes indicated the resident returned from Good Samaritan Hospital with an abrasion to the left elbow following the fall. The facility’s Resident Rights policy stated that residents are guaranteed certain basic rights, including the right to a dignified existence.
Failure to Ensure Timely Assessment, Physician Notification, and Documentation for Change in Condition and Fall Incident
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents by not ensuring timely assessment, physician notification, or complete documentation during significant changes in condition and after an incident. For one resident with a history of hemiplegia, traumatic brain injury, diabetes, and memory deficits, staff did not perform a timely assessment or notify the physician when the resident complained of malaise and was subsequently transported to the hospital by his wife. Documentation was incomplete regarding the events leading up to the transfer, and the physician was not notified until several hours after the resident had already left the facility. The resident was later admitted to the hospital for suspected sepsis related to a complicated urinary tract infection, with symptoms of fever, chills, and malaise reported for several days prior to admission. For another resident with disseminated coccidioidomycosis and a thoracic spinal cord injury, staff did not notify the physician or conduct a thorough investigation after the resident experienced a fall. The clinical record and progress notes showed no evidence of physician notification following the fall, and the responsible nurse confirmed that neither the physician was notified nor the incident endorsed to the next shift. The interdisciplinary team note regarding the fall was created 11 days after the incident, and the investigation was incomplete, as not all involved staff were interviewed and there were discrepancies in the documentation of the circumstances surrounding the fall. Facility policies required prompt assessment, physician notification, and thorough documentation in the event of a change in condition or incident. However, in both cases, staff failed to follow these protocols, resulting in delayed notification and incomplete documentation. These failures were confirmed through interviews with staff and review of facility records and policies.
Failure to Accurately Assess and Care Plan for Elopement Risk
Penalty
Summary
Licensed nurses failed to accurately complete an elopement and wandering risk assessment for a resident with severe cognitive impairment and multiple diagnoses affecting cognition, including cerebral palsy, chromosomal abnormality, and developmental delay. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and there was a documented incident where the resident eloped from the facility during a shift change. However, the elopement and wandering risk assessment did not reflect the resident's diagnoses, with relevant sections left blank or incorrectly marked, and the assessment did not indicate the presence of cognitive-impacting diagnoses. Additionally, there was no care plan developed to address elopement or wandering risks for the resident, despite facility policy requiring care plans for residents identified as at risk. Both the assistant director of nursing and the licensed vocational nurse who completed the assessment confirmed that the documentation was inaccurate and incomplete. Facility policies reviewed stated that residents at risk for wandering or elopement should have care plans with strategies and interventions to maintain safety, which was not done in this case.
Failure to Update PASRR for Resident with New Mental Disorder
Penalty
Summary
The facility failed to update a Level I Preadmission Screening and Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental disorder. The resident, who was admitted in 2007, had a medical history that included major depressive disorder and mood disorder, with a new diagnosis of psychotic disorder in June 2023. Despite this new diagnosis, the facility did not update the resident's PASRR Level I Screening, which was last completed in March 2022 and indicated a need for a Level II evaluation. Interviews with facility staff, including an MDS Licensed Vocational Nurse and the Director of Nursing, confirmed that an updated PASRR should have been completed following the new diagnosis. The facility's policy on admission criteria, updated in October 2024, also specified that a new PASRR should be completed for residents with new mental illness diagnoses. However, the resident's medical record showed no evidence of an updated PASRR after the diagnosis of psychotic disorder.
Failure to Ensure Accurate PASRR Screenings for Mental Disorders
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) Level I screenings accurately reflected the presence of diagnosed serious mental disorders for two residents. Resident #127 was admitted with a medical history of schizoaffective disorder and schizophrenia, and was discharged from the hospital with orders for risperidone, an antipsychotic medication. However, the initial PASRR Level I screening completed at the hospital did not indicate the presence of these serious mental disorders, despite the resident receiving psychotropic medication for schizoaffective disorder. The facility did not submit a new Level I screening after the resident remained in the facility for more than 30 days, as required. Similarly, Resident #25 was admitted with a history of multiple mental health diagnoses, including schizophrenia, major depressive disorder, bipolar disorder, anxiety disorder, and borderline personality disorder. The initial PASRR Level I screening completed at the hospital only reflected the diagnosis of schizophrenia and omitted the other mental health conditions. The facility also failed to submit a new Level I screening after the resident remained in the facility for more than 30 days, despite the initial screening's inaccuracies. Interviews with facility staff, including the Admissions Director, Medical Records Director, MDS RN, and the Director of Nursing, revealed a lack of awareness and responsibility for ensuring the accuracy of PASRR screenings. The staff acknowledged that new Level I screenings should have been completed for both residents due to the inaccuracies in the initial screenings and the residents' extended stays in the facility. The facility's policy required all new admissions and readmissions to be screened for mental disorders, but this was not effectively implemented in these cases.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey. Eight plastic containers of bleach were found with open lids, exposing their contents in various locations such as on top of garbage hampers and isolation bins outside residents' rooms. This was confirmed by the Director of Staff Development (DSD), who acknowledged that the lids should have been closed to prevent exposure. Additionally, two Certified Nursing Assistants (CNAs) were observed wearing the same gloves while moving from room to room without performing hand hygiene between tasks, which they admitted was against infection control protocols. Further observations revealed that a box of clean gloves and a bottle of hand sanitizer were placed too close to an open trash bin on a treatment cart, which was confirmed by a Licensed Vocational Nurse (LVN). Three laundry hampers with linens on top were improperly stored outside by the facility's patio, and a bin overflowing with housekeeping towels was found outside the laundry area hallway. The Environmental Director confirmed that these items should have been stored properly to prevent contamination. Additionally, a housekeeping cart contained a mix of clean and potentially contaminated items, such as empty drinking water bottles and opened gloves, which was acknowledged by the DSD as inappropriate storage. Resident 1's nasal cannula was found hanging and touching a wheelchair, which the DSD confirmed should have been stored in a mesh bag to prevent contamination. Lastly, a red pushcart with used meal trays and utensils was parked underneath a water and juice dispenser in the nursing station, which the DSD confirmed was an infection control issue. The facility's policies on hand hygiene, glove use, and standard precautions were reviewed, indicating expectations for proper infection control practices that were not adhered to in these instances.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was admitted with diagnoses including dementia, type 2 diabetes mellitus, and essential hypertension, received quetiapine fumarate (Seroquel) without adequate indication and monitoring of specific target behaviors for its use. The resident's Minimum Data Set indicated a BIMS score of 99, showing an inability to complete the cognitive assessment. A family member requested Seroquel, which was not included in the discharge orders from the emergency room, leading to a new physician order for the medication without specifying its indication or monitoring requirements. The Licensed Vocational Nurse confirmed that the family member requested the medication, and the physician was contacted to obtain the order. The Pharmacy Consultant noted that a new admission review recommended monitoring target behaviors and side effects, but this was not documented in the medication administration record. The facility's policy on antipsychotic medication use requires documentation of the necessity and monitoring of such medications, which was not adhered to in this case.
Infection Control Breach in Covid-19 Isolation Room
Penalty
Summary
The facility failed to adhere to infection prevention practices for a resident in a Covid-19 isolation room. During an observation, it was noted that the door to the isolation room was open, contrary to infection control guidelines. The resident in question was admitted with acute pulmonary edema and acute and chronic respiratory failure with hypoxia, and was confirmed Covid-19 positive on the day of the observation. A Licensed Vocational Nurse confirmed the resident's Covid-19 status and acknowledged that the door should have been closed. The Infection Preventionist also stated that the door should remain closed to contain the infection, aligning with CDC guidelines that require the door of a room with a suspected or confirmed SARS-CoV-2 infection to be kept closed.
Inadequate Infection Control Practices for Emergency Crash Carts
Penalty
Summary
The facility failed to implement proper infection control practices for three out of four emergency crash carts. Specifically, crash carts B and C contained oropharyngeal airway (OPA) kits that were not stored in their original packaging and lacked labels indicating shelf-life expectancy or expiration dates. During an observation with the Director of Nursing and the Infection Control Preventionist Nurse (ICPN), it was confirmed that the OPAs were stored in plastic bags without proper labeling. The Central Supply (CS) staff acknowledged that the OPAs had been stored improperly for some time and could not locate the original packaging. Additionally, crash cart A contained OPAs stored in plastic bags with a yellowish substance and no expiration date. The ICPN confirmed the presence of the substance and the lack of labeling. Furthermore, crash carts B and C contained a Yankauer suction tip and an adult nasal oxygen cannula, both without shelf-life expectancy or expiration dates. The facility's policy required that emergency carts be maintained with a checklist and that medical supplies be replaced as needed if packaging was compromised, but these protocols were not followed.
Failure to Conduct Thorough Investigations of Resident Altercations
Penalty
Summary
The facility failed to conduct thorough investigations and report the outcomes for several alleged altercations involving residents. Specifically, the investigation summaries for altercations between Residents 2 and 3, Residents 1 and 2, and Residents 4 and 5 did not indicate whether the facility was able to determine if the altercations occurred. During interviews and record reviews, it was confirmed that there were no conclusions documented for these incidents, indicating a lack of thoroughness in the investigation process. The facility's administrator acknowledged that the 5-day follow-up investigations were not thorough or clear, and they did not adhere to the facility's policy and procedure for abuse reporting and investigation. The policy requires that all reports of resident abuse be thoroughly investigated and documented, with findings reported to local, state, and federal agencies. However, the facility's follow-up investigation reports failed to provide sufficient information to describe the results of the investigations or indicate any corrective actions taken if the allegations were verified.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to ensure that three residents were kept free from constipation due to not following physician orders for bowel management interventions. Resident 8, who had diagnoses including hemiplegia, metabolic encephalopathy, constipation, and dementia, did not have a bowel movement from May 9 to May 12, 2024. Despite physician orders for Milk of Magnesia (MOM), Bisacodyl suppository, and Fleet enema, these interventions were not administered as prescribed. MOM was not given from May 1 to May 16, and Bisacodyl and Fleet enema were delayed or improperly administered. Resident 9, diagnosed with dementia and requiring assistance with personal care, experienced constipation episodes from May 5 to May 9, May 14 to May 17, and May 24 to May 27, 2024. The physician orders included MOM, mineral oil enema, and Bisacodyl suppository, but none of these were administered throughout May 2024. Similarly, Resident 10, with conditions such as anemia, atrial fibrillation, and chronic systolic heart failure, did not have bowel movements from May 26 to May 29, 2024. Despite having orders for MOM, Fleet enema, and Bisacodyl suppository, these were not given during May 2024. Interviews with facility staff revealed a lack of adherence to the bowel management protocol. Licensed Vocational Nurse A acknowledged that residents should be considered constipated after 48 hours without a bowel movement and that MOM should be administered first, followed by other interventions if necessary. However, the MARs did not reflect the administration of these medications. The Director of Nursing confirmed that CNAs report bowel movements in the electronic health record, and nurses are responsible for checking and following up with the constipation protocol. The facility's policy indicated that the nurse should review records daily and administer medication as ordered, which was not followed in these cases.
Failure to Inform Responsible Party of Resident's Appointment
Penalty
Summary
The Social Service Director (SSD) at the facility failed to inform the responsible party (RP) of a resident about the resident's appointment with a psychologist. This oversight was identified during an interview and record review, where it was found that the SSD did not document the communication of the appointment date to the RP in the social service notes. The SSD acknowledged the lapse in documentation, which is crucial for ensuring that the RP can participate in the resident's treatment decisions. The resident involved had multiple complex medical conditions, including Hemiplegia and Hemiparesis following a cerebral infarction, aphasia, dementia, Parkinsonism, major depressive disorder, and bipolar disorder. The resident was not self-responsible and had a designated RP to make decisions on their behalf. Despite receiving verbal permission from the RP to sign consent for a psychological evaluation, the SSD did not document informing the RP about the psychologist's appointment date, which led to the RP being unable to attend the session.
Use of Space Heater in Rehabilitation Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident when a space heater was used in the rehabilitation room. This deficiency was identified during an interview with a resident who reported that the therapy staff could not turn up the space heater, and she was not allowed to have a space heater or heating pad, while the rehabilitation staff used a space heater. The resident mentioned that the space heater had been in use for six months due to a malfunctioning heating unit, which left the rehabilitation room cold without it. During a facility tour, a space heater was observed plugged in and turned on under a desk in the rehabilitation room. The rehabilitation staff confirmed the use of the space heater for four to six months due to issues with the facility's heating and cooling system. The Director of Nursing acknowledged the observation and removed the space heater, stating that staff could not use it. The Maintenance Supervisor confirmed that space heaters were not allowed and could not provide maintenance logs for the heating and cooling system. The facility's policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 424 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Empress Care Center, Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| A Grace Sub Acute & Skilled Care | 1.2 mi | ★★★★★ | 3 | 0 |
| The Redwoods Post-acute | 1.2 mi | ★★★★★ | 1 | 0 |
| Skyline Healthcare Center - San Jose | 1.3 mi | ★★★★★ | 1 | 0 |
| O'connor Hospital D/p Snf | 1.3 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.