Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Brookdale Greenwood Village during CMS and state inspections, most recent first.
A resident with sepsis, Alzheimer’s disease, repeated falls, and documented need for at least contact guard or stand‑by assist with a walker was allowed to ambulate outside unaccompanied. The care plan identified fall risk and general fall precautions but did not specify the required supervision level for ambulation, and therapy notes showed the resident was not cleared for independent ambulation, especially on uneven surfaces or outdoors. Staff interviews revealed inconsistent understanding of the resident’s mobility status, incomplete special instructions regarding fall risk and assistance needs, and conflicting statements about whether the resident was considered safe to walk alone. The resident went outside alone, was later found on the ground near the parking lot with a newspaper and her walker nearby, reported tripping and falling, and was noted to have oral bleeding and pain with movement; hospital imaging confirmed facial bone and coccyx fractures.
Failure to prevent and treat a heel pressure injury: A dependent resident with dementia and impaired mobility was admitted with no pressure injuries, but the facility did not complete a Braden assessment on admission or implement heel offloading and a low-air loss mattress in a timely manner. Surveyors observed the resident’s heels repeatedly left on the bed or recliner surface, including during care and checks when staff did not offload them. The resident later developed a stage 3 pressure injury to the right heel, and wound care findings showed slough, granulation tissue, and drainage.
Improper Hand Hygiene and Glove Use During Meal Service: Staff in two kitchenettes repeatedly handled ready-to-eat foods, meal tickets, utensils, and equipment with the same gloves or after touching other surfaces without washing hands. A cook and dietary aides continued food prep across multiple tasks, including handling resident food, touching a resident, cracking eggs, and working with raw egg on gloves, while only briefly washing hands or not changing gloves between tasks.
The facility failed to consistently complete grievance forms and document its response to resident and group complaints about staffing and delayed call light response. Residents reported long waits for assistance, including call lights taking 30 minutes to 1.5 hours, and said weekends and nights were especially short-staffed. Staff also confirmed that staffing was insufficient, showers and other care tasks were delayed, and residents frequently complained, but no staffing grievances were documented.
Infection control practices were not maintained for residents on EBP. Staff entered a resident’s room and provided incontinence care without gowns, an RN removed wound dressing material without a gown, and a CNA provided colostomy and linen care without a gown despite door signs indicating EBP. Staff reported not seeing the sign, not knowing why EBP supplies were present, or not having gowns available. The facility also used the same blood pressure cuff on two residents without disinfecting it between uses, and the LPN said he forgot to sanitize it.
A resident with diagnoses including depression, anxiety, PTSD, and delusional disorder received clonazepam, mirtazapine, venlafaxine, and olanzapine before informed consent was signed for each medication. The resident was cognitively intact, and the DON and LPNs stated psychotropic medication consents should be completed before administration and should include risks, benefits, and side effects.
Expired and discontinued medications were found in a medication cart during survey observation. A resident's hydrocodone/acetaminophen and another resident's discontinued hydromorphone remained in the cart, along with an opened bottle of senna without an expiration date and an opened bottle of simethicone that had expired. An LPN said carts should be checked daily and expired medications discarded immediately, and the ADON said nursing staff and unit managers were responsible for ensuring no expired or discontinued medications remained in the carts.
Incomplete Hospice Communication and Documentation: A resident receiving hospice care had severe cognitive impairment and was dependent for all ADLs, but the EMR lacked routine hospice visit documentation. The hospice binder showed multiple hospice RN visits and CNA care entries, yet only one hospice visit note was present and there was no documentation that hospice staff communicated the care provided to facility staff. Interviews showed the LPN did not review the binder, the health information specialist depended on requests to obtain notes, and the NHA said hospice notes were not sent regularly.
Failure to Offer and Document Flu and Pneumococcal Vaccinations: Two residents were affected by vaccine process failures. One resident over 65 with cognitive impairment signed a pneumococcal consent form, but the specific vaccine was not identified, the form was undated, and there was no EMR evidence the vaccine was administered. Another resident with hemiplegia/hemiparesis, DM2, and depression had an MDS showing memory impairment and supervision needs, yet the influenza vaccine was not offered and the consent form in the chart was unsigned.
Failure to document and provide COVID-19 vaccination: The facility did not properly track COVID-19 immunization status for two residents. One resident had consented to the vaccine, but the vaccine was not yet administered, and another resident’s record did not show whether the vaccine had been offered or whether it was refused or contraindicated. Both residents were older adults with significant medical conditions, and their MDS assessments showed they were not up to date on COVID-19 vaccination.
Kitchen sanitation, food storage, and ice machine cleaning deficiencies: Surveyors found a soiled paper towel dispenser, dirty walls, and a drying rack with stacked pans trapping moisture and food debris. They also observed opened, undated, expired, and improperly stored food items, including uncovered pastries, a dented can stored with other cans, open bins without labels, and food boxes on the floor. The ice machine had debris, smudges, splatters, and a crusted white substance on the exterior and interior surfaces, and the DM could not provide proof of recent professional deep cleaning.
Ordered Admission Medications Not Available: A resident with cirrhosis, HTN, bipolar disorder, and DM did not receive several ordered meds on admission, including rifaximin, risperidone, and midodrine, because they were not available from the pharmacy. The MAR and progress notes confirmed missed doses, and the pharmacy director said rifaximin was delayed due to an insurance issue and a delay in the facility’s written agreement to cover the cost. The DON said he did not know why the meds were missed or why delivery was delayed.
Failure to assess and implement fall precautions for a resident with orthostatic hypotension: A resident with repeated falls and orthostatic hypotension was admitted with hospital instructions to wear an abdominal binder and compression stockings before standing, but the facility did not build the diagnosis into the initial fall plan, did not document transfer assistance needs in the ADL care plan, and did not ensure the binder was applied before the resident fell in the bathroom while trying to transfer off the toilet without assistance. Nursing notes documented a skin tear and that standing BP was not checked to evaluate orthostatic hypotension, and the DON stated there had been no formal staff training on orthostatic hypotension fall prevention.
Two residents with OSA did not receive CPAP care consistent with orders and standards. One resident’s CPAP order was not implemented until after admission, and the resident’s representative reported the resident said staff had not assisted with CPAP use. Another resident’s CPAP mask and machine were left uncovered on a nightstand, and staff were unsure about the ordered cleaning method, with the DON stating there was no recent training on proper CPAP use and cleaning.
The facility failed to provide adaptive dining equipment for three residents who required it. One resident with dysphagia and Alzheimer's disease used cups without handles, another with dysphagia and dementia used glass goblets and a soda can, and a third with multiple sclerosis was observed without a plate guard. The registered dietician confirmed the shortage of Kennedy cups and makeshift solutions being used.
The facility failed to store, prepare, distribute, and serve food in a sanitary manner. Observations revealed improperly labeled and dated food items and inappropriate handling of ready-to-eat foods by a dietary aide, who did not perform hand hygiene or change gloves as required.
The facility failed to maintain an effective infection control program, leading to deficiencies in housekeeping protocols, isolation precautions, and hand hygiene practices. Housekeeping staff did not follow proper cleaning protocols, and staff did not use PPE correctly or offer hand hygiene to residents before meals. Additionally, the facility's water management plan was outdated and incomplete.
The facility failed to offer choices to two residents for their bathing schedules, assigning shower days based on room numbers rather than individual preferences. Both residents expressed discomfort and lack of autonomy in their bathing routines, and staff interviews confirmed that the schedules were pre-determined by the facility.
The facility failed to provide necessary personal hygiene services for two residents. One resident had long, soiled fingernails despite needing assistance, and another resident did not receive required help with oral hygiene, with no proper documentation in place.
The facility failed to ensure that two residents received care according to professional standards and their care plans. One resident did not have blood pressure and heart rate consistently assessed before administering Metoprolol, and another resident's weights were not obtained as ordered, with no reweigh conducted after a significant weight change.
The facility failed to provide proper foot care for two residents, one with severely overgrown and discolored toenails and another with an overgrown toenail, despite documented needs and requests for care. Staff were unclear about responsibilities and procedures for addressing these needs.
The facility failed to ensure an environment free from accident hazards for two residents at risk for falls by not maintaining their beds in the lowest position when they were in bed. Both residents were repeatedly found in high bed positions without staff present, despite being identified as fall risks and members of the Falling Star Program. The care plans for both residents did not document the need for the bed to be in the lowest position.
The facility failed to provide effective pain management for a resident, as they did not complete comprehensive pain assessments, document the resident's pain management goals, or consistently administer and evaluate the effectiveness of pain medications. The resident reported significant pain in her left knee, which was not adequately addressed in her care plan.
The facility failed to ensure residents were free from significant medication errors by not following physician-ordered parameters for midodrine administration for a resident. Despite orders to hold the medication if the systolic blood pressure (SBP) was above 120 mmHg, the medication was administered 26 times when the SBP was above this threshold, including three instances where the SBP was above 140 mmHg.
The facility failed to ensure medication carts were locked when unattended, as observed on two occasions. Medication carts were found unlocked with keys inserted, and no nurse was visible nearby. Staff interviews confirmed that carts should be locked at all times, and the DON acknowledged the issue and indicated steps were being taken to prevent future lapses.
The facility failed to ensure adequate hydration and provide the correct consistency of thickened liquids for two residents. One resident, with significant cognitive impairment, was given nectar thick liquids instead of honey thick liquids and had fluids out of reach, leading to dehydration. Another resident, with a history of aspiration problems, was given regular consistency water instead of nectar thick liquids. Staff interviews revealed a lack of understanding and adherence to the prescribed liquid consistencies.
The facility failed to administer the pneumococcal vaccination to a resident after consent was provided. The resident's electronic medical record indicated that the vaccination was not given, and the consent form was signed as verbal, indicating refusal, which contradicted the resident representative's interview. The infection preventionist and director of nursing confirmed the discrepancy and planned to contact the resident's representative to clarify their wishes.
The facility failed to post nurse staffing information in a prominent place accessible to residents and visitors. Observations revealed no staffing information posted on the third floor, and the Director of Nursing confirmed that the information was kept in binders behind the nurses' stations, restricted to facility and agency staff only.
Failure to Supervise High-Risk Resident During Ambulation Outside
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate use of assistive devices to prevent accidents for a resident with known fall risk and mobility impairments. The resident was admitted with diagnoses including sepsis, unsteadiness on feet, generalized muscle weakness, repeated falls, and Alzheimer’s disease. A recent MDS showed moderate cognitive impairment, need for a walker, substantial to maximal assistance with toilet transfers, and partial to moderate assistance with walking 50 feet, with walking on uneven surfaces and curbs not attempted. The facility’s falls management policy required evaluation of fall risk and implementation of an IDT fall prevention plan for high‑risk residents, but the resident’s care plan, while identifying fall risk and listing general fall interventions, did not specify the level of supervision required for ambulation. Facility records and therapy documentation showed that the resident required at least contact guard or stand‑by assistance for ambulation and transfers and was not safe to ambulate independently, particularly on uneven surfaces or outside. A functional assessment documented use of a front‑wheel walker with contact guard assist on level surfaces and dependence on staff for uneven surfaces. PT notes described gait training with a front‑wheel walker and contact guard assist, need for verbal cueing for posture and step placement, impulsive transfer behavior despite maximal cues, and toilet transfers requiring minimal assistance and constant cueing. A social services note stated the resident required contact guard assist for all mobility. The director of rehabilitation later confirmed that the resident was not independent with ambulation, had not been cleared to walk independently in hallways or outside, and that therapy had not worked with her on uneven surfaces or curbs. On the day of the fall, documentation and interviews indicated the resident had been working with PT on gait training with stand‑by assist earlier in the evening. Nursing notes indicated the resident had a history of getting up unassisted, walking with her walker or holding onto furniture, and required frequent reminders that staff needed to be with her when walking; she was placed on frequent room checks for this behavior. That evening, staff last recalled seeing the resident near the nurses’ station before she went outside unaccompanied. She was later found on her back on the ground outside near the parking lot, approximately 30 feet from the front door, fully clothed with shoes on and holding a newspaper, with her walker nearby. She reported that she had tripped and fallen forward, hitting her head, and complained of pain when attempts were made to move her. She was noted to be bleeding from her mouth, and subsequent hospital imaging documented fractures of facial bone sockets and a closed coccyx fracture. The facility’s post‑event analysis identified that the resident went outside unaccompanied and was not using an assistive device at the time of the fall, with being unaccompanied outside listed as a contributing factor, despite her documented need for assistance and lack of clearance for independent ambulation, especially outdoors. Interviews with multiple staff members further demonstrated inconsistency and lack of clarity regarding the resident’s ambulation status and supervision needs. Some staff, including CNAs and LPNs, stated the resident was a one‑person assist and was not supposed to go outside alone, while the director of rehabilitation was initially documented in the facility’s investigation as saying the resident was safe to ambulate alone and go outside alone near the patio table, a statement later contradicted by therapy records and her own subsequent interview. The IDT post‑event analysis inaccurately documented that the resident ambulated with no problems with the use of a device. CNAs also reported that special instructions in the computer system did not always indicate fall risk status or required assistance level. The investigation interviews lacked documented dates and times, and there were discrepancies between RN accounts regarding whether one RN left the resident briefly with another family before obtaining additional help. Collectively, these documented actions and omissions show that the resident, known to be at high risk for falls and requiring at least stand‑by or contact guard assistance, was allowed to ambulate outside unaccompanied without clearly defined and communicated supervision parameters, resulting in a fall with fractures.
Failure to Prevent and Treat a Heel Pressure Injury
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and treat a pressure injury for a dependent resident who was admitted with a right hip surgical incision and no pressure injuries. The resident had dementia, impaired mobility, and was dependent on staff for all activities of daily living. Although the resident was identified as being at risk for pressure injuries, the facility did not implement heel offloading interventions or provide a low-air loss mattress on admission, and a Braden Scale assessment was not completed until after the resident developed a right heel pressure injury. Survey observations showed the resident’s heels were repeatedly left in contact with the bed or recliner surface. On one observation, the resident was transferred from bed to wheelchair and then to a recliner, and her heels were left resting on the recliner surface. On another observation, the resident remained lying on her back for more than three hours without repositioning, and her heels were left touching the recliner surface after transfer. Additional observations showed the resident in bed with her heels directly on the mattress, including times when staff entered the room for care or checks but did not offload the heels. The resident was also observed moving her heels back and forth against the bed. The resident developed a stage 3 pressure injury to the right heel 17 days after admission. During wound care observation, the resident did not have an air mattress on the bed, and the wound bed contained yellow slough with red granulation tissue and reddish drainage. The wound care physician later documented the wound as a stage 3 pressure injury measuring 2.5 cm by 2.0 cm by 0.4 cm with granulation and slough. Staff interviews indicated that the only intervention initially in place was keeping the resident’s feet from touching the recliner surface while sitting, and the DON stated that protective boots were requested after she observed the resident crossing her leg and moving her heel against the mattress.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in two kitchenettes because staff did not perform proper hand hygiene and glove changes during meal service. The deficiency was identified through observations of meal preparation and service activities in the second-floor and third-floor kitchenettes, where staff repeatedly handled ready-to-eat foods, meal tickets, utensils, and equipment while wearing the same gloves or after touching other surfaces without washing hands. In the third-floor kitchenette, a cook handled hamburger buns, lettuce, tomatoes, meal tickets, yogurt, plates, and the microwave while wearing the same gloves for extended periods. He removed gloves and washed his hands only briefly on two occasions, washing for approximately 10 seconds and approximately seven seconds, before putting on new gloves and continuing to assemble meals. He also touched meal tickets, used a food processor, handled food from the microwave, and continued assembling plates without changing gloves between tasks. In the second-floor kitchenette, an unidentified dietary aide touched a resident with gloved hands and then returned to preparing room trays without changing gloves. The aide also handled plastic wrap used to cover desserts and drinks, including touching the rims of glasses where residents put their mouths, and later put on new gloves without washing hands after retrieving a key from a pocket and opening a kitchen door. Another dietary aide brought food into the kitchenette without washing hands, uncovered food and placed it in the steam table without hand hygiene, and later handled muffins, toast, butter, bacon, sausage, bread, eggs, bananas, pudding, and meal tickets while continuing to wear the same gloves across multiple tasks. The aide also cracked eggs several times, got raw egg on her gloves, and continued food preparation without changing gloves. During interview, the aide stated she only changed gloves when leaving the service line or touching items outside the service line, and the executive chef stated staff should change gloves and wash hands when changing tasks, including after touching raw meat or cracking eggs.
Incomplete Grievance Handling for Staffing Complaints
Penalty
Summary
The facility failed to complete grievance forms consistently and did not effectively address, resolve, or document its response to resident and group grievances related to staffing and call light response times. The grievance policy stated that residents, representatives, family members, visitors, or advocates could file verbal or written grievances, and that outcomes would generally be reported within seven working days, with progress reviewed at morning stand-up meetings until resolution. However, when surveyors requested staffing grievances for the prior three months, the nursing home administrator reported that the facility had no documented staffing grievances. During a group interview, four alert and oriented residents said they had ongoing concerns about staffing and long call light wait times. Two recently admitted residents said they had not been informed how to submit a grievance. One resident said she had repeatedly asked for more CNAs during resident council meetings for three years and felt nothing was done. The residents reported that on most weekends there was only one CNA for three halls, that call lights could take up to an hour and a half to be answered, and that staffing was even worse during holidays. Individual resident interviews and staff interviews supported the same concerns. One resident reported waiting 45 minutes on the toilet for help, another said call lights often took over 30 minutes to be answered, and a resident reported only one CNA for an entire shift one weekend. CNAs and LPNs stated that staffing was insufficient, showers and repositioning were delayed, residents sometimes received bed baths instead of showers, and call light response times could be around 30 minutes. Several staff members said residents frequently complained about staffing, but grievances were not filed, and one staff member said families were asked to complete grievance forms themselves.
Infection Control Failures With EBP and Shared Blood Pressure Cuff Use
Penalty
Summary
The facility failed to maintain infection control practices for residents on enhanced barrier precautions (EBP). During a continuous observation, two unidentified staff members entered a resident’s room and provided incontinence care without putting on gowns, even though the resident’s door sign indicated that staff must wear gloves and a gown for high-contact resident care activities. A CNA later stated she had not received training on the new EBP sign posted on the resident’s door and did not know why the EBP supplies were there, and she also said gowns were not available in the PPE hanging on the door. Additional observations showed other staff not following EBP requirements. An RN removed gauze from a resident’s left leg while the resident was in a wheelchair and wore gloves but no gown, despite a sign on the door indicating the resident was on EBP. Another CNA emptied a resident’s colostomy bag and changed bed sheets while the resident’s abdomen was exposed and the resident was receiving care, and the CNA wore gloves and a face mask but no gown. The CNA stated she did not see the sign on the door, acknowledged she should have worn a gown, and said the facility had provided education regarding EBP. The IP stated that the sign on one resident’s door should have been changed to contact precautions after the resident returned from the hospital with MRSA, and said it was her responsibility to change the sign and ensure PPE was available. The facility also failed to clean shared blood pressure cuffs between residents. An LPN used the same electronic blood pressure cuff on one resident and then on another resident shortly afterward without disinfecting or sanitizing it in between. The LPN stated he used the same cuff on all residents, that residents did not have individual cuffs, and that he forgot to sanitize it after the prior use. The IP confirmed that the facility used one blood pressure cuff for multiple residents and that nursing staff were responsible for sanitizing the cuff after each use on a resident.
Psychotropic Medication Consent Obtained After Administration
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications for one resident reviewed for unnecessary medications. Resident #4 was admitted with diagnoses including delusional disorders, cognitive communication deficit, depression, anxiety disorder, and post-traumatic stress disorder. The 3/29/26 MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for most ADLs. The resident was receiving clonazepam, mirtazapine, venlafaxine, and olanzapine, all identified as psychotropic medications. Record review showed the first doses of clonazepam, mirtazapine, venlafaxine, and olanzapine were administered before the informed consents were signed. The consents for all four medications were signed on 3/23/26, after the medications had already been given. Staff interviews confirmed that medication consents were supposed to be obtained before administration, and the DON stated psychotropic medications should not have been given before the consents were signed because the resident needed to know the clinical side effects and the risks versus benefits of the medications.
Expired and Discontinued Medications Left in Medication Cart
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted professional principles in one of five medication carts. During observation of the second floor north medication cart, the drawer for Resident #29 contained hydrocodone/acetaminophen 5 mg/325 mg oral tablets with an order date listed, and the drawer for Resident #22 contained hydromorphone 2 mg oral tablets with a discontinued order date listed. In the over-the-counter medication drawer, surveyors found an opened bottle of senna 8.6 mg oral tablets that did not have an expiration date on the bottle and an opened bottle of simethicone 80 mg oral tablets that had expired. During interview, the LPN stated nursing staff were responsible for checking medication carts every day to ensure there were no expired or discontinued medications left in the carts, and that expired medications should be discarded immediately. She said she would remove the medication from her cart and advise the DON to dispose of it. The ADON stated nursing staff and unit managers were responsible for ensuring there were no expired or discontinued medications and said she would provide education to floor nurses and unit managers regarding the facility's responsibility of immediately discarding expired and discontinued medications.
Incomplete Hospice Communication and Documentation
Penalty
Summary
The facility failed to meet requirements for the provision of hospice care for one resident receiving hospice services. Resident #7, who had diagnoses including dementia, acute kidney failure, and acute chronic respiratory failure with hypoxia, had severe cognitive impairment with a BIMS score of 4 out of 15 and was dependent on staff for all ADLs. The resident was admitted to hospice care services, and the facility policy stated that hospice progress notes were to be included in the medical record and nursing associates were to be informed of any changes recommended by hospice staff. Record review showed the resident's EMR contained only one hospice-related verbal medication order and did not include routine hospice visit documentation. The hospice binder at the nurse's station contained the hospice care plan, CNA bath and skin check notes, verbal orders, and a sign-in sheet showing multiple hospice RN visits, but it contained only one hospice care visit note. There was no documentation that communication occurred between hospice staff and facility staff regarding the care provided during the numerous hospice RN visits. Staff interviews indicated the LPN did not look in the binder and was unaware of hospice notes being uploaded into the EMR, the health information specialist relied on requests from nursing leadership to obtain hospice notes, and the NHA stated the hospice agency did not send visit notes regularly and the facility had not reached out to resolve the record request situation.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures related to influenza and pneumococcal immunizations for two residents reviewed for immunizations. The deficiency involved one resident who had consented to receive the pneumococcal vaccine but there was no documentation that the vaccine was administered, and another resident whose influenza vaccine was not offered. The report states the facility had policies requiring residents or their representatives to be offered these vaccines, informed, and documented appropriately. Resident #6 was over 65 years old and had diagnoses including pancreatic insufficiency, depression, and dysphagia. The March 2026 MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15 and indicated the resident was not up to date with pneumococcal vaccination because the vaccine had not been offered by the facility. Record review showed the resident signed a pneumococcal vaccine consent form stating he received information and consented to the vaccine, but the form did not identify the specific vaccine and did not include a signature date. There was no documentation in the EMR showing the pneumococcal vaccine had been given. Resident #30 was under 65 years old and had diagnoses including hemiplegia or hemiparesis, diabetes mellitus type II, and depression. The March 2026 MDS documented short- and long-term memory problems, moderate impairment in decision-making for daily tasks, and a need for cueing and supervision. The assessment also stated the resident did not receive the influenza vaccine in the facility for that season and that the vaccine was not offered. The EMR contained an influenza vaccine informed consent form with the resident's name, but it was not signed by the resident or the resident's representative.
Failure to Document and Provide COVID-19 Vaccination
Penalty
Summary
The facility failed to develop and implement policies and procedures related to immunizations for two residents reviewed for COVID-19 vaccination status. The report states that the facility did not ensure the COVID-19 vaccine was provided to one resident after education and consent, and did not ensure another resident’s medical record documented whether the COVID-19 vaccine had been offered or whether the resident did not receive it because of a medical contraindication or refusal. Resident #2 was greater than 65 years old and had diagnoses including hemiplegia and hemiparesis, long-term use of anticoagulants, chronic respiratory failure, and high blood pressure. The resident’s MDS documented that the COVID-19 vaccination was not up to date and did not state whether the vaccine had been offered or why it was not received. Review of the EMR did not reveal documentation that the facility offered the SARS-COV-2 vaccine to the resident. Resident #7 was greater than 65 years old and had diagnoses including dementia, acute kidney failure, acute respiratory failure, and anxiety. The resident’s MDS documented that the COVID-19 vaccination was not up to date and did not include whether the vaccine had been offered or the reason it was not received. Review of the EMR did not reveal documentation that the facility offered the SARS-COV-2 vaccine to the resident or the resident’s representative.
Kitchen sanitation, food storage, and ice machine cleaning deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional food safety standards in the main kitchen. During the kitchen tour, the paper towel dispenser over the handwashing sink was soiled with smudges and dried debris, the walls behind the handwashing station and around the walk-in refrigerator had brown and yellow streaks and splatters, and the drying rack had multiple food storage bins and pans stacked together so moisture was trapped, with unidentifiable food debris found between two pans. The facility also failed to ensure that perishable foods were properly labeled, stored, and maintained. In the dry storage area, surveyors observed an opened bag of chips, uncovered and undated pastries and pies, expired popcorn, a dented can stored with non-dented cans, a flour bin lid with smudges and dried debris and a use-by date of 8/1/25, and boxes of food on the floor. In the main kitchen, a bin of grains was left open without a lid and had no use-by date. In the walk-in refrigerator and dry storage room, food boxes were stacked on the floor, a box of carrots was left open in the freezer, and a separate bin of carrots in the walk-in refrigerator was labeled as watermelon with an expiration date of 8/1/25. The facility also failed to maintain the ice machine in a sanitary condition. Surveyors observed debris across the front and sides of the machine, dark smudges, brown splatters, and a crusted white substance on the outside and inside door of the ice machine, and similar smudges, splatters, and debris on the inside door-flap. The ice machine cleaning log showed monthly cleaning entries from January through August 2025, and the dietary manager stated he could not provide documentation that the ice machine had been deep-cleaned by a professional service provider in the last six months and said the facility no longer contracted with the outside service for deep sanitation and chemical disinfection.
Ordered Admission Medications Not Available
Penalty
Summary
The facility failed to ensure a resident received the highest practicable treatment and care when ordered medications were not obtained and administered upon admission. The resident had cirrhosis of the liver, hypertension, bipolar disorder, and diabetes mellitus, and was cognitively intact with a BIMS score of 13 out of 15. Physician orders included rifaximin for cirrhosis, risperidone for bipolar disorder, and midodrine for hypotension, all ordered on the same day during admission processing. Review of the MAR and progress notes showed the resident did not receive rifaximin on two scheduled doses because it was not available, did not receive risperidone at bedtime because it was not available, and did not receive midodrine because it was not available. The record confirmed the medications were missed because they were unavailable. A physician assistant later documented that the resident had multiple comorbidities requiring medication management and frequent clinical evaluations, and that without regular monitoring and management the resident was at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. Interviews showed the resident’s representative believed the facility discontinued rifaximin because it could not be obtained from the pharmacy and said she brought medications from home, including rifaximin, because she suspected missed doses, but staff would not accept them for administration. Staff stated the pharmacy was expected to supply ordered medications and that family-supplied medications generally would not be used. The pharmacy operation director said rifaximin was delayed because insurance rejected the order and the facility took two days to provide a written agreement to cover the cost, and the DON said he did not know why several medications were missed after admission or why delivery was delayed.
Failure to assess and implement fall precautions for a resident with orthostatic hypotension
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for a resident with a history of repeated falls and orthostatic hypotension. The resident was admitted with diagnoses including orthostatic hypotension, repeated falls, and unsteadiness on the feet, and the hospital discharge instructions documented that the resident had fallen due to blood pressure dropping when standing and that an abdominal binder and compression stockings were to be worn prior to standing. The facility did not incorporate the orthostatic hypotension diagnosis and related fall history into the resident’s initial fall prevention planning on admission. After admission, the resident’s fall care plan included general interventions such as keeping the call light in reach, providing therapy as ordered, and encouraging appropriate footwear. The record showed that the resident’s ADL care plan did not document transfer care and assistance needs, even though the resident’s point of care task record showed dependence on staff for all transfers. The resident’s medication administration record also showed that the abdominal binder was not applied prior to the fall incident, despite the hospital discharge instructions to wear it when standing. The resident fell in the bathroom while attempting to transfer off the toilet without assistance. Nursing documentation described the resident found on the bathroom floor with a skin tear and bleeding on the right forearm/wrist. A change of condition note documented sitting blood pressure, but standing blood pressure was not assessed to evaluate orthostatic hypotension as a possible factor in the fall. The post-fall review noted the resident remained a fall risk, and the abdominal binder intervention was not added until after the fall. The DON stated there had been no formal training for staff, specifically CNAs, on orthostatic hypotension fall prevention.
Failure to Provide Ordered CPAP Care and Proper Cleaning
Penalty
Summary
The facility failed to ensure that two residents who required respiratory care received CPAP treatment consistent with physician orders and professional standards of practice. One resident had diagnoses including obstructive sleep apnea, end stage renal disease, diabetes, and hypertension, and the hospital paperwork indicated CPAP use, but the June 2025 orders did not document CPAP therapy. Although the resident was admitted earlier, the CPAP order was not implemented until 7/8/25. The resident’s representative stated the resident reported not being assisted with the CPAP after admission, and the representative said the CPAP machine was brought in without delay. A second resident with obstructive sleep apnea, chronic kidney disease, arthritis, and gout was observed with the CPAP mask sitting uncovered on the nightstand and exposed to potential contaminants. The resident stated staff assisted with the CPAP each night and morning, filled the water reservoir with distilled water, and left water in the machine if any remained. The resident also stated he had not seen staff clean the machine, tubing, or mask since admission, and during the interview the machine and mask were not under any protective covering. Record review and staff interviews showed the resident’s baseline care plan was not implemented until several days after admission, and the CPAP mask cleaning order for weekly vinegar soaking was entered later. An RN stated she washed the mask in warm soapy water and dried it before placing it back beside the bed, but she also said she did not know the vinegar order and was unaware of the manufacturer instructions. The DON stated staff were responsible for admission paperwork and baseline care planning, but also said he was not aware of recent training on proper CPAP use and cleaning. Staff interviews further showed confusion about where vinegar was stored and what it was used for.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide accessible dining equipment and utensils for three residents who required adaptive equipment. Resident #22, diagnosed with dysphagia and Alzheimer's disease, was observed using cups without handles and a straw, contrary to the care plan that specified the use of a nosey cup and two-handled mug. Similarly, Resident #18, diagnosed with dysphagia, parkinsonism, and dementia, was observed using glass goblets and a soda can with a straw instead of the prescribed Kennedy cups and plate guard. The care plan for Resident #18 included occupational therapy screening and providing adaptive equipment as needed, which was not adhered to during the observations. Resident #1, diagnosed with multiple sclerosis, was observed without a plate guard during lunch service, despite the care plan indicating the need for a plate guard and handled cups. The registered dietician (RD) confirmed that both dietary and nursing staff were responsible for ensuring residents received the necessary equipment. The RD also mentioned that the facility was running low on Kennedy cups and had been using makeshift solutions like plastic wrap over cups with straws. These observations and interviews indicate a failure to provide the required adaptive dining equipment as per the residents' care plans.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in two satellite kitchens. Specifically, the facility did not ensure that food was labeled, dated, and disposed of in a timely manner. Observations revealed an opened carton of soy milk with an expiration date of 1/21/24 and two opened Hormel thick and Easy Clear thickener drinks without any date of opening. The dietary manager discarded these items after review. The registered dietitian confirmed that opened containers should have an open-by and use-by date and that the soy milk should have been discarded by 1/21/24. Additionally, the facility failed to handle ready-to-eat foods appropriately. During the noon meal service, a dietary aide was observed placing serving utensils into pans with bare hands, failing to perform hand hygiene before donning gloves, and using the same gloved hands to handle various food items without changing gloves. The dietary manager confirmed that ready-to-eat foods should be handled with utensils or clean gloves.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, leading to several deficiencies across two units. Housekeeping staff did not follow proper cleaning protocols, such as cleaning from cleaner to dirtier areas and changing gloves and performing hand hygiene between cleaning the bathroom and bedroom. Observations revealed that the housekeeping supervisor cleaned the toilet before the sink and did not change gloves or perform hand hygiene after cleaning the bathroom and before handling other cleaning supplies. Interviews with the housekeeping supervisor and the infection preventionist confirmed these lapses in protocol, which could potentially spread bacteria or viruses within the facility. The facility also failed to ensure proper isolation precautions and the appropriate use of personal protective equipment (PPE). Observations showed that a certified nurse aide (CNA) did not don an N95 mask before entering a COVID-19 positive resident's room, and another staff member wore a surgical mask under an N95 mask, contrary to CDC guidelines. Interviews with the infection preventionist confirmed that staff should wear an N95 mask before entering a COVID-19 positive room and should not wear a surgical mask underneath. Additionally, the facility did not ensure that staff performed hand hygiene or offered it to residents before meals. Observations in the dining room and resident rooms showed that staff did not offer hand hygiene to residents before serving meals. The dietary manager and the director of nursing acknowledged that hand hygiene should be performed before meals and that hand wipes were previously used but had been discontinued. Furthermore, the facility's water management plan was outdated and lacked specific details, such as the current staff responsible for the plan and a complete diagram of the water system. Interviews with the nursing home administrator and interim maintenance director revealed that the plan had not been reviewed or updated to reflect the current staff and facility layout.
Failure to Offer Resident Choice in Bathing Schedule
Penalty
Summary
The facility failed to offer choices to residents for activities of daily living (ADL), specifically in ensuring that two residents received showers according to their preferred frequency. Resident #1, who has multiple sclerosis, respiratory failure, and neuromuscular dysfunction of the bladder, reported that she did not have a choice of when she bathed and had to take her bed bath when it was offered or it would not be done. The resident's bath days were pre-determined by the facility and not re-offered if missed. Similarly, Resident #23, who has heart failure, respiratory failure, cataracts, and arthritis, stated that her shower days were assigned to her and she did not have any choice about her shower preferences, which were dependent on staff workload rather than her own preferences. Both residents expressed discomfort with the current shower assignments and felt they lacked autonomy in their bathing schedules. Staff interviews corroborated the residents' statements, revealing that bathing schedules were assigned based on room numbers and not individual resident preferences. CNA #2 and CNA #3 confirmed that residents did not choose their shower days, which were scheduled upon admission based on room assignments. The Director of Nursing (DON) claimed that residents had choices for when they bathed and that the shower assignment sheet was merely a guideline. However, the evidence from resident and staff interviews indicated that the facility's practice did not align with the DON's statement, as residents' shower days and times were indeed assigned according to their room numbers, limiting their ability to exercise self-determination in their daily care routines.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents. Resident #49, a 77-year-old with diagnoses including alcohol abuse and adult failure to thrive, required partial to moderate assistance with activities of daily living (ADL). Observations revealed that Resident #49's fingernails were long, discolored, and visibly soiled with a dark substance under several nails. Despite the resident's attempts to trim his own nails and the comprehensive care plan indicating the need for nail care, staff did not offer assistance. Interviews with CNAs and an LPN confirmed that Resident #49's nails were overgrown and unclean, and the facility's nail care policy was not provided for review. Resident #23, over the age of 65 with diagnoses including heart failure, respiratory failure, cataracts, and arthritis, required substantial assistance with oral hygiene. The resident reported needing help with setting up oral care supplies and stated that staff often forgot to assist with brushing her teeth. The comprehensive care plan did not document the resident's oral care assistance needs, and there was no documentation in the electronic medical record indicating that the resident received the necessary assistance. Interviews with a CNA, an LPN, and the DON confirmed the lack of proper documentation and assistance for Resident #23's oral care.
Failure to Monitor Vitals and Obtain Weights
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. For Resident #47, the facility did not consistently assess and document blood pressure and heart rate prior to administering Metoprolol, a beta-blocker medication. This failure occurred on multiple occasions in March 2024, and there was no documentation indicating that the resident's vitals were assessed before the medication was held on one occasion. Interviews with staff revealed that the electronic charting system did not prompt nurses to document the resident's vitals due to incorrect input of the physician's order, and there was a lack of proper documentation by CNAs as well. For Resident #16, the facility did not obtain weights according to the physician's orders. The resident, who had multiple comorbidities including hemiplegia, diabetes, and heart failure, was supposed to be weighed weekly for three weeks following admission. However, weights were not consistently documented, and there was no reweigh conducted when a significant weight change was noted. Additionally, there was no documentation that the provider or registered dietitian was notified about the missed weights or the weight change. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the facility's policy required weights to be obtained and documented, and any refusals or discrepancies should be addressed promptly. The RD emphasized the importance of accurate weight monitoring for understanding the resident's health status. The failure to follow these protocols led to deficiencies in the care provided to both residents.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for two residents, Resident #49 and Resident #16, as per the standards of practice. Resident #49, a 77-year-old male with diagnoses including alcohol abuse and adult failure to thrive, had severely overgrown and discolored toenails, with one toenail curving completely over the toe pad. Despite being signed up for podiatry services, there was no documentation of him receiving these services, and staff interviews revealed uncertainty about whether he had been offered additional podiatry services after initially refusing them. The care plan and physician notes indicated a need for nail care, but this was not adequately addressed by the facility staff. Resident #16, who had multiple diagnoses including hemiplegia, hemiparesis, diabetes mellitus type two, and severe cognitive impairment, also did not receive proper foot care. Her left big toenail was observed to be significantly overgrown, and despite her expressing a desire for nail care, there was no documentation in her electronic medical record indicating that her nail care needs were addressed. Staff interviews revealed a lack of awareness about her condition and a misunderstanding of responsibilities regarding nail care for diabetic residents. The facility's policy and procedure for foot care were requested but not provided, and there was a general lack of clarity among staff about the process for identifying and addressing residents' need for podiatry services. The Director of Nursing acknowledged the deficiencies and indicated that assessments for ancillary services were done at least annually, but this did not translate into timely and effective care for the residents in question.
Failure to Maintain Bed Position for Fall-Risk Residents
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for two residents, both of whom were at risk for falls. Specifically, the facility did not maintain the beds of Resident #6 and Resident #41 in the lowest position when the residents were in bed, as required by the facility's Falls Management and Falling Star Program policies. Observations revealed that both residents were repeatedly found in beds that were in a high position without staff present, despite being identified as fall risks and members of the Falling Star Program. Resident #6, who had severe cognitive impairment and required substantial assistance with daily activities, was observed on multiple occasions lying in bed with the bed in a high position. The resident's care plan, which identified the resident as a fall risk and a member of the Falling Star Program, did not document the need for the bed to be in the lowest position when the resident was in bed. The DON confirmed that the bed should have been in the lowest position and adjusted it accordingly during the survey. Similarly, Resident #41, who had moderate cognitive impairment and required substantial assistance with daily activities, was also observed lying in bed with the bed in a high position on multiple occasions. The resident's care plan identified the resident as a fall risk and a member of the Falling Star Program but failed to document the need for the bed to be in the lowest position. Staff interviews revealed a lack of consistent understanding and adherence to the facility's protocol for maintaining bed positions for fall-risk residents.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide an effective pain management regime for a resident, identified as Resident #216, who required such services. The facility did not complete a comprehensive pain assessment that identified the onset, presence, and duration of the resident's pain. Additionally, the resident's goal for pain management and acceptable level of pain were not documented. The care plan did not specify the location of the resident's pain or include non-pharmacological interventions to help alleviate the pain. The resident reported significant pain in her left knee, which was not adequately addressed in her care plan or pain assessments. The medication administration record (MAR) revealed inconsistencies in the administration of pain medications. Oxycodone was not administered on several occasions, and there was no documentation explaining why the medication was not given or if the physician was notified. The resident's pain levels were not consistently assessed before or after the administration of acetaminophen and oxycodone, and there was no follow-up to determine the effectiveness of these medications. The resident's pain levels were frequently above five out of ten, indicating that the pain management interventions were not effective. Interviews with staff, including an LPN and the DON, highlighted gaps in the facility's pain management practices. The LPN acknowledged that the resident was in pain and that the pain was primarily in her left knee. However, the pain medication orders were not updated to reflect this. The DON confirmed that pain assessments should be completed every shift and should cover various aspects of the resident's pain, but these assessments were not adequately documented for Resident #216. The DON also noted that the facility had an emergency medication stock, but it was unclear why the resident did not receive her prescribed oxycodone on certain days.
Failure to Follow Physician-Ordered Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of midodrine for Resident #265. The resident, who was over the age of 65 and had diagnoses including myelodysplastic syndrome, orthostatic hypotension, and high cholesterol, was prescribed midodrine to be administered three times a day with the condition that it should be held if the systolic blood pressure (SBP) was above 120 mmHg. However, the February medication administration record (MAR) documented 26 instances where midodrine was administered despite the resident's SBP being above the physician-ordered parameter, including three instances where the SBP was above 140 mmHg. Interviews with facility staff, including an LPN, the DON, the pharmacist, and the medical director, confirmed that medication orders, including blood pressure parameters, should always be followed. The staff acknowledged the importance of adhering to these parameters to prevent adverse effects, such as elevated blood pressure. The failure to follow the physician's orders for midodrine administration led to significant medication errors, as documented in the report.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in accordance with professional standards on two of six medication carts. Specifically, the medication carts were left unlocked when unattended. On one occasion, a medication cart in the middle hallway of the third floor was observed with keys inserted and dangling from the lock in the unlocked position, with no nurse visible nearby. This situation persisted for several minutes until an LPN returned, acknowledged the mistake, and secured the cart. On another occasion, a medication cart in the left hallway of the third floor was also found unlocked and unattended for several minutes until another LPN returned and locked it. Interviews with staff confirmed that medication carts should be locked at all times and keys should never be left in the carts. The LPNs involved admitted to the lapses, and the Director of Nursing (DON) reiterated the policy that medication carts must be properly secured and that nurses should always have the keys in their possession. The DON indicated that steps were being taken to prevent such occurrences in the future.
Failure to Ensure Adequate Hydration and Correct Liquid Consistency
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, Resident #31 and Resident #266, by not encouraging fluid intake and not providing the correct consistency of thickened liquids as per physician's orders. Resident #31, who had significant cognitive impairment and required maximum assistance with eating and drinking, was observed with fluids out of reach and was given nectar thick liquids instead of the prescribed honey thick liquids. This resident had a history of dehydration and was receiving IV fluids for suspected dehydration, yet her fluid intake was not adequately monitored or recorded in the medical record. Staff interviews revealed a lack of understanding of the differences between nectar and honey thick liquids, and the resident's fluid intake was not properly tracked or encouraged as per the facility's policy. The resident's representative also noted that the resident needed fluids within reach, which was not consistently done. Resident #266, who had moderate cognitive impairment and a history of aspiration problems, was observed with regular consistency water and an Ensure nutritional shake instead of the prescribed nectar thick liquids. Staff interviews confirmed that the resident required nectar thick liquids, but there was a failure to provide the correct consistency, posing a risk of aspiration. The speech language pathologist's evaluation and physician's orders clearly indicated the need for nectar thick liquids, yet this was not adhered to by the facility staff. The facility's policies on thickened liquids and hydration were not followed, leading to these deficiencies. The director of nursing and registered dietitian acknowledged the importance of providing the correct liquid consistency to prevent aspiration and the need for monitoring fluid intake, but there was a lack of proper implementation and communication among the staff. The facility's failure to ensure residents received the correct consistency of liquids and adequate hydration resulted in potential health risks for the residents involved.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to implement policies and procedures related to pneumococcal immunizations for one of the five residents reviewed for immunizations. Specifically, the facility did not administer the pneumococcal vaccination to Resident #6 after consent was provided. According to the CDC's Recommended Immunization Schedule for Adults, individuals over the age of 65 should receive one dose of PCV15 followed by PPSV23 or one dose of PCV20 if they lack documentation of vaccination or evidence of past infection. Resident #6, who was over the age of 65 and had diagnoses including chronic kidney disease, osteoporosis, and gout, did not receive the pneumococcal vaccination despite the resident representative's desire for the resident to be up to date on all vaccinations. The resident's electronic medical record revealed that the pneumococcal vaccination was not administered, and the consent form was signed as verbal, indicating refusal, which contradicted the resident representative's interview stating they wanted the resident to receive the vaccination. The infection preventionist (IP) and director of nursing (DON) were interviewed and confirmed that it was unclear who refused the vaccines on the consent form. The IP, who started working at the facility in January 2024, stated that the nurse was responsible for offering the necessary immunizations and obtaining consent. If a resident was eligible for a vaccine but did not want it, they would sign the consent indicating refusal. However, in this case, the consent form for Resident #6 was not signed by the family representative, leading to confusion about the resident's vaccination status. The IP and DON acknowledged the discrepancy and planned to contact the resident's representative to confirm their wishes regarding the vaccinations.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place, readily accessible to residents and visitors. Observations on 3/26/24 at 4:01 p.m. revealed no nurse staff posting on the third floor, where a binder labeled 'staffing information' was found but restricted to facility and agency staff only. The Director of Nursing (DON) confirmed on 3/28/24 at 10:07 a.m. that the staffing information was typically posted at the nurses' station or on a board near the nurses' station, but it was currently in binders located behind the nurses' stations on the second and third floors. The DON was unsure why the binder was restricted and acknowledged that the nursing staffing schedule was not posted in a visible area for residents and visitors to view.
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 470 citations issued within 25 miles in the last 12 months — including the 8 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 Greenwood Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Suites At Holly Creek Care Center, The | 2.1 mi | ★★★★★ | 0 | 0 |
| Orchard Park Health Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Suites At Someren Glen Care Center, The | 2.7 mi | ★★★★★ | 4 | 0 |
| Beth Israel At Shalom Park | 3.6 mi | ★★★★★ | 10 | 0 |
| Hampden Hills Post Acute | 4.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brookdale Greenwood Village.
100% money-back within 48 hours.
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.