Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Harmony Pointe Care Center during CMS and state inspections, most recent first.
The facility failed to provide residents with access to their personal funds on weekends, as revealed by resident interviews and staff admissions. A broken lock box, meant for emergency access, had not been replaced for months, and the nursing supervisor was unaware of weekend access procedures. A sign indicating banking hours was only posted after the survey began, highlighting a lack of communication and oversight.
A facility failed to provide a homelike environment for a resident, whose room lacked personalization and essential supplies. Maintenance issues were widespread, with broken fixtures and damaged areas reported by residents. Staff interviews revealed unclear responsibilities for room personalization and a slow maintenance process, relying on text messages rather than an electronic system.
The facility failed to provide meaningful activities for residents, including those with severe cognitive impairments. A resident was left in her room without engagement, another was not assisted to attend activities despite her interest, and a third was left without meaningful activities at the nurses' station. Residents on the secured unit also lacked activity stimulation.
Expired medications were found in two medication carts and a storage room, including atropine, calcium with vitamin D, abacavir and lamivudine, daptomycin, and Dermaprep. Staff interviews revealed lapses in checking expiration dates, with a CNA and RN acknowledging the oversight. The DON stated that daily checks should prevent such occurrences, indicating a failure in protocol execution.
The facility failed to provide food that was palatable in taste, texture, and temperature. Residents reported cold and flavorless meals, and observations showed food was left on uninsulated carts for extended periods. The dietary manager cited a broken plate warmer and lack of hot boxes as contributing factors, while the nursing home administrator was aware of the issues but had not resolved them.
The facility failed to maintain an effective infection prevention and control program, with housekeeping staff not disinfecting high-touch surfaces and not following proper hand hygiene. Linen was transported uncovered, and equipment used for multiple residents was not cleaned regularly. Additionally, residents were observed sharing utensils and food items without staff intervention, increasing the risk of infection spread.
A cognitively intact resident, dependent on staff for daily activities, was left in a hospital gown during Bible study, despite her preference to be dressed in a dress. Staff interviews revealed a lack of awareness and communication regarding her preferences, leading to the deficiency.
A facility failed to notify a resident's medical POA about her medical appointments, despite the resident's cognitive intactness and the POA's request for notification. The resident, with a history of significant medical conditions, was not informed about her appointments, and the facility's SSD mistakenly notified the financial POA instead. The DON acknowledged the error, highlighting a communication breakdown in the facility's protocol.
A resident in a LTC facility did not have a privacy curtain in their room, leading to concerns about exposure during daily groin treatment. The resident, who was cognitively intact and required assistance with daily activities, expressed fear of being exposed. Staff interviews revealed unawareness of the missing curtain, and the resident was asked to use the bathroom for privacy during treatment.
A facility failed to ensure two residents were free from physical restraints. One resident with Alzheimer's was placed in a secured unit for over 11 hours without proper authorization after an altercation, while another resident with severe cognitive impairments was effectively restrained by being positioned at a table with a locked wheelchair, unable to move freely. The facility's actions were inconsistent with their policy, and staff interviews revealed a lack of awareness and inappropriate handling of these situations.
A resident with severe cognitive impairments was involved in an altercation with another resident, resulting in a head injury. The incident was not reported to the State Agency within the required timeframe due to a delay in notifying the NHA, contrary to the facility's policy.
A facility failed to include a resident's use of hearing aids and compression socks in their comprehensive care plan. The resident, with moderate cognitive impairment and multiple health issues, was observed without these items despite instructions for staff to assist. The care plans lacked necessary interventions, and staff interviews confirmed the oversight.
A resident with a deep tissue pressure injury on her right heel did not receive consistent care as per her care plan, which included heel protection boots and a wheelchair cushion. Despite physician recommendations, observations showed the resident often without these interventions. Staff interviews revealed a lack of awareness or misunderstanding of the care plan, and there was no documentation of the resident's refusal to wear the heel protection boot prior to the survey.
A resident with limited range of motion was not placed on a maintenance program after physical therapy was discontinued, despite her desire to regain some independence in activities of daily living. The facility staff did not document offering a restorative program, and the resident was left without necessary support to maintain her functional status.
A resident at high risk for falls was repeatedly found with her call light out of reach, despite facility policies requiring it to be accessible. Observations showed the call light was often placed behind her or on the bed, preventing her from calling for assistance. Staff interviews confirmed the resident's history of falls and the need for the call light to be within reach, highlighting a failure to consistently implement fall prevention measures.
A facility failed to provide appropriate interventions for a resident with schizoaffective disorder, anxiety, and dementia. The resident exhibited aggressive behavior and repeatedly requested a smoke break and assistance, but an LPN did not redirect or acknowledge her needs. Additionally, the resident's request to use the bathroom was delayed, and a report of being hit was not taken seriously by staff. The care plan included interventions for verbal and physical aggression, but these were not consistently implemented.
A facility failed to ensure a resident was free from unnecessary medications by prescribing Seroquel for insomnia, an unapproved off-label use. The facility did not follow the recommended gradual dose reduction from 50 mg to 25 mg and lacked documentation of consent for the medication's use during the current admission. The social services consultant acknowledged the absence of clinical justification and failure to follow up on the dose reduction recommendation.
Inadequate Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents could access their personal funds accounts on weekends, which is a violation of their right to manage their financial affairs. Interviews with two residents revealed that they could only access their funds when the business office staff was present, and they had to request money on Fridays if they needed it for the weekend. Observations confirmed that there was no sign indicating banking hours until a sign was posted later, which stated limited weekday hours and mentioned emergency access in very small print. Staff interviews highlighted that the business office manager was aware of the limited access and mentioned a broken lock box that was supposed to be used for emergency access on weekends. The lock box had been broken for a few months, and the nursing supervisor on duty was unaware of the procedure for weekend access. The nursing home administrator was not informed about the broken lock box until the survey, indicating a lack of communication and oversight in ensuring residents' financial access needs were met.
Facility Fails to Provide Homelike Environment and Maintenance
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident #91, as well as for other residents in the facility. Resident #91's room was not personalized, lacking decorations and personal items, despite his preferences for having books, music, and personal belongings related to his interests in painting and animals. Observations revealed that his call light was inaccessible and non-functional, and his room was bare with missing furniture parts and essential supplies like towels and trash bags. Interviews with staff indicated a lack of clarity on which department was responsible for assisting residents in personalizing their rooms. Additionally, the facility failed to maintain resident rooms, hallways, and dining rooms adequately. Observations across the facility showed various maintenance issues, including chipped door frames, non-functional toilets, missing baseboards, broken window blinds, cracked light fixtures, stained carpets, and damaged floor tiles. These issues were reported by residents, who expressed dissatisfaction with the conditions and the impact on their daily living, such as difficulty maneuvering wheelchairs over damaged tiles. Interviews with the maintenance director and nursing home administrator revealed a lack of an effective system for tracking and addressing maintenance issues. The maintenance director relied on text messages from staff rather than using the facility's electronic work system, and there was only one maintenance person responsible for the entire building. The approval process for repairs was noted to be slow, especially for costs exceeding $2500, which required the nursing home administrator's approval. Despite daily walk-throughs by the maintenance director and nursing home administrator, the facility struggled to address the numerous maintenance concerns promptly.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities to support the physical, mental, and psychosocial well-being of residents, particularly for three residents outside of the secured unit and all residents on the secured unit. Resident #91, who had severe cognitive impairment and enjoyed activities such as painting and listening to music, was observed spending long periods in his room without being invited to group activities or receiving any meaningful interaction from staff. Despite having a care plan that included activities of interest, Resident #91 was not engaged in these activities, and staff failed to document the type of one-to-one activities offered. Resident #96, who also had severe cognitive impairment and required assistance with mobility, was frequently observed sitting at the nurses' station without any activity materials or meaningful engagement. Although she enjoyed social activities and music, she was not assisted to attend scheduled activities such as music programs and bingo. The activity documentation inaccurately recorded her refusal to participate in activities, despite observations showing she was not approached by staff to attend. Similarly, Resident #301, with severe cognitive impairment and mobility issues, was often left without meaningful activities. She was observed sitting at the nurses' station or in bed without being invited to participate in scheduled activities. The activity documentation indicated she refused activities, but observations showed she was not approached by staff. Additionally, residents on the secured unit were left without meaningful activity stimulation, with staff failing to engage them in activities or provide appropriate materials.
Expired Medications Found in Medication Carts and Storage Room
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards, as observed in two of five medication carts and one of three medication storage rooms. Specifically, expired medications were found in these areas, which is against the guidelines set by the United States Food and Drug Administration (USFDA). The expired medications included atropine, calcium with vitamin D, abacavir and lamivudine, daptomycin, and Dermaprep liquid barrier skin preparation. These findings indicate a lapse in the facility's medication management practices. During interviews, staff members acknowledged the presence of expired medications. A certified nurse aide with medication authority admitted that the atropine should have been removed from the cart upon expiration. A registered nurse noted that the calcium with vitamin D was newly delivered and should have been checked for expiration before being placed in the cart. The Director of Nursing stated that nurses were responsible for daily checks of medication carts for expired items, indicating a failure in the execution of this protocol. These observations and interviews highlight the facility's deficiency in maintaining proper medication storage and labeling practices.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, and temperature. Multiple residents reported that the food was often served cold and lacked flavor. Observations during meal preparation and service revealed that food was placed on styrofoam plates, covered with plastic wrap, and left on uninsulated carts for extended periods before being served, contributing to the food being served at inadequate temperatures. The dietary manager acknowledged the issue of cold food and attributed it to a malfunctioning plate warmer, which had not been repaired for some time. Additionally, the facility lacked hot boxes for transporting room trays, further exacerbating the problem of maintaining food temperature. The dietary manager also noted that the use of styrofoam plates was due to a temporary water shut-off, which prevented the use of regular plates. Interviews with staff and review of food committee meeting notes indicated that there was a lack of effective communication and resolution regarding residents' concerns about food quality. The dietary manager mentioned that few residents attended the food committee meetings, and there was no documentation of resolutions to issues raised, such as inconsistent serving of vegetables. The nursing home administrator was aware of the complaints but had not taken effective measures to address the underlying issues, such as the lack of hot boxes and the broken plate warmer.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Housekeeping staff did not disinfect high-touch surfaces such as call lights, door handles, and light switches in resident rooms. Additionally, the cleaning process did not follow the recommended order from clean to dirty areas, and hand hygiene was not performed correctly. Specifically, a housekeeper was observed applying hand sanitizer for less than the recommended time and donning gloves on wet hands, which compromised the effectiveness of the hand hygiene process. Furthermore, the housekeeper did not clean high-touch surfaces and used contaminated towels during the cleaning process. The facility also failed to ensure that linen was transported and stored appropriately. Observations revealed that clean linen carts were left uncovered in hallways, exposing them to potential contamination. This practice was contrary to the facility's policy, which required clean linen to be covered during transport and storage. Interviews with staff confirmed that linen should be covered to prevent contamination, but this was not consistently practiced. Additionally, equipment used for multiple residents, such as mechanical lifts, was not cleaned regularly. A sit-to-stand lift was observed with debris and dirt, indicating a lack of regular cleaning. Furthermore, residents were observed sharing utensils and food items, which could lead to the spread of infections. Staff did not intervene when residents shared plates and utensils during meal times, despite acknowledging that such practices could spread viruses. These deficiencies highlight significant lapses in the facility's infection control practices, potentially compromising resident safety.
Failure to Honor Resident's Dressing Preferences for Bible Study
Penalty
Summary
The facility failed to honor the preferences of an 88-year-old resident who was cognitively intact and dependent on staff for all activities of daily living, including dressing. The resident expressed a strong preference to be dressed in her dress for Bible study, which was an important activity for her. However, on the day of the Bible study, she was left in a hospital gown because the staff did not assist her in getting dressed in time, causing her embarrassment. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. The certified nurse aide (CNA) responsible for the resident was unaware of the Bible study schedule and the resident's desire to be dressed for it. Additionally, the social services director and the nursing home administrator were not fully informed about the resident's participation in Bible study or her dressing preferences, indicating a breakdown in communication and documentation of resident preferences.
Failure to Notify Medical POA of Resident's Appointments
Penalty
Summary
The facility failed to notify the medical power of attorney (POA) for a resident regarding her medical appointments, which is a requirement for maintaining proper communication and care coordination. The resident, an 86-year-old woman with a history of a right femur fracture, cerebral infarction, dysphagia, muscle weakness, and Parkinsonism, was cognitively intact and required assistance with mobility. Despite her cognitive status, the resident expressed that she was not informed about a recent doctor's appointment, nor was her daughter, who held the medical POA. The resident's representative confirmed that she had instructed the facility to notify her of any medical issues or appointments, but this was not done for appointments in August and September. The facility's social services director (SSD) and director of nursing (DON) were involved in arranging and notifying representatives about medical appointments. However, the SSD admitted to notifying the financial POA instead of the medical POA for the resident's appointments, despite being informed by the medical POA to contact her for such matters. The DON acknowledged that the medical POA should have been notified and that the facility's protocol was to contact the medical POA when both financial and medical POAs were listed. This oversight led to a communication breakdown, resulting in the medical POA not being informed of the resident's medical appointments.
Privacy Curtain Deficiency for Resident Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during care, specifically by not providing a privacy curtain in the resident's room. The resident, who was cognitively intact and required supervision or assistance for all activities of daily living, expressed concern about being exposed during daily groin treatment due to the absence of a privacy curtain. An observation confirmed that the resident's room lacked a privacy curtain, which was necessary to maintain privacy during such treatments. Interviews with facility staff, including a CNA and an LPN, revealed that they were unaware of the absence of a privacy curtain in the resident's room. The CNA mentioned that the resident was mostly independent with activities of daily living, while the LPN stated that the resident was asked to go into the bathroom for privacy during treatment. The nursing home administrator and the director of nursing were also unaware of the missing privacy curtain and acknowledged that every resident should have one to ensure privacy during care.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, as required by their policy. Resident #91, who had Alzheimer's disease and severe cognitive impairments, was involved in an altercation with another resident. Following this incident, the facility staff placed Resident #91 in a secured unit for over 11 hours without a physician's order, consent from the resident's responsible party, or an assessment to determine the appropriateness of this action. This was done in an attempt to control his behaviors, but the resident continued to display aggressive behaviors while in the secured unit. Resident #66, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was observed being positioned in front of a table with his wheelchair locked, preventing him from moving freely. Despite being in the dining room for extended periods, Resident #66 was unable to unlock his wheelchair or self-propel, effectively restraining him without a physician's order for restraints. The facility's staff did not provide any activities or engage the resident during these times, contrary to the care plan that suggested frequent checks and engagement. The facility's actions were inconsistent with their policy, which stated that physical restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. Interviews with staff, including the social services director and the director of nursing, revealed a lack of awareness and inappropriate handling of the situations involving both residents. The facility did not document Resident #91's time in the secured unit, and Resident #66 was left without activities or engagement, highlighting a failure to meet the residents' needs and ensure their freedom from restraints.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation that resulted in an injury to the State Survey and Certification Agency in a timely manner, as required by state law. The incident involved a 76-year-old resident with severe cognitive impairments, including Alzheimer's disease and dementia, who was struck in the head by another resident after a verbal altercation. The altercation led to a laceration on the resident's forehead. Despite the facility's policy requiring immediate reporting of such incidents, the altercation, which occurred on 8/31/24, was not reported or investigated until 9/3/24. Interviews with facility staff revealed that the incident was not communicated to the Nursing Home Administrator (NHA) until after the holiday weekend, delaying the investigation and reporting process. The NHA acknowledged that the incident should have been reported to the State Agency within two hours due to the resulting injury. The delay in reporting was attributed to the staff's failure to notify the NHA promptly, highlighting a lapse in adherence to the facility's abuse reporting policy.
Failure to Address Hearing Aids and Compression Socks in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, which did not address the use of hearing aids and compression socks. The resident, a 74-year-old with multiple diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease, was observed not wearing her hearing aids or compression socks on multiple occasions. Despite having a sign in her room instructing staff to assist with these items, the resident reported that staff did not put her hearing aids in or her compression socks on, and at one point, she was told her compression socks were in the laundry. The care plans in place for the resident did not include necessary interventions for her hearing aids and compression socks. The communication care plan did not mention the use of hearing aids, and the activities of daily living care plan omitted the need for assistance with both hearing aids and compression socks. Additionally, there was no documentation in the electronic medical record indicating that the resident was receiving the required assistance. Interviews with staff, including a CNA and the DON, confirmed that the comprehensive care plan should have included these details to ensure proper care was provided.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary treatment and services to prevent pressure injuries for a resident, identified as Resident #20, who had a deep tissue pressure injury on her right heel. Despite physician recommendations for heel protection boots and a wheelchair cushion, these interventions were not consistently applied. Observations revealed that Resident #20 was often seen without a cushion in her wheelchair and without heel protection boots on both feet, contrary to her care plan. Resident #20, an 86-year-old resident with a history of a right femur fracture, cerebral infarction, dysphagia, muscle weakness, and Parkinsonism, was at risk for developing pressure injuries. Her care plan included the use of heel protection boots on both feet and a pressure-relieving wheelchair cushion. However, multiple observations during the survey period showed that these measures were not consistently in place, as she was frequently seen wearing tennis shoes and without a wheelchair cushion. Interviews with staff, including CNAs and RNs, indicated a lack of awareness or misunderstanding regarding the resident's care plan. The Director of Nursing acknowledged that the resident was refusing to wear the heel protection boot, but there was no documentation of this refusal in the resident's electronic medical record prior to the survey. This lack of documentation and adherence to the care plan contributed to the deficiency in providing adequate pressure ulcer care.
Failure to Provide Maintenance Program Post-Therapy
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services after the discontinuation of physical therapy. The resident, an 88-year-old woman with chronic respiratory failure, COPD, bipolar disorder, and Alzheimer's disease, was cognitively intact and dependent on staff for all activities of daily living. She had been on a prescribed physical therapy program, which was discontinued without placing her on a maintenance program, despite her expressed desire to regain some independence in her activities of daily living. The resident reported that she had received physical therapy a few months prior, but it had stopped without explanation. She expressed a desire to perform some activities of daily living independently, such as sitting up in bed and transferring to a wheelchair. Although she was given a sheet of exercises by the physical therapist, the facility staff were not instructed to assist her, making it difficult for her to perform the exercises on her own. The resident stated that she was not offered a maintenance program, which she would have liked to have been part of. Interviews with facility staff revealed that the director of rehabilitation acknowledged that typically, residents are placed on a restorative program after therapy is discontinued. However, there was no physician's order for such a program for this resident, and the physical therapist did not document offering or discussing a restorative program. The nursing home administrator confirmed that restorative services should be offered to all residents discontinued from therapy services, and such programs should be documented in the medical record with a physician's order.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision for a resident identified as high risk for falls. The resident, an 86-year-old with a history of multiple falls, was observed multiple times with her call light out of reach, despite being cognitively intact and requiring substantial assistance with transfers. The facility's fall management policy emphasized the importance of keeping personal items, including the call light, within reach to prevent falls, yet this was not consistently implemented for the resident. The resident had a history of eight falls over a period of several months, with various interventions documented in her care plan, such as educating her to use the call light and keeping her within staff eyesight. Despite these interventions, observations revealed that the call light was often placed in locations inaccessible to the resident, such as clipped behind her pillow or laying on the bed, which contributed to her inability to call for assistance when needed. Interviews with facility staff, including a CNA and an RN, confirmed that the resident was known to attempt self-transfers and that the call light should have been within her reach at all times. The staff acknowledged the importance of ensuring the call light was accessible, yet the deficiency persisted, indicating a lack of consistent implementation of the fall prevention interventions outlined in the resident's care plan.
Failure to Implement Person-Centered Interventions for Resident with Mental Disorder
Penalty
Summary
The facility failed to provide appropriate person-centered interventions for a resident diagnosed with schizoaffective disorder, depressive episodes, anxiety, and dementia. The resident, who had moderate cognitive impairment and was dependent on staff for personal care, exhibited verbal behaviors and rejected care. During observations, the resident repeatedly asked an LPN for a smoke break and assistance with personal needs, but the LPN did not attempt to redirect the resident's aggressive behavior or acknowledge her requests. Additionally, the resident's request to use the bathroom was delayed by seven minutes, and when the resident reported being hit, a staff member did not address the situation seriously. The care plan for the resident indicated a history of verbal and physical aggression, with interventions to offer tasks that diverted attention. However, staff interviews revealed that these interventions were not consistently implemented. The DON stated that staff should redirect the resident by offering activities or engaging in conversation, while the clinical consultant emphasized the need for firm boundary setting and spending time with the resident. Despite these guidelines, the staff's actions and inactions during the observed incidents did not align with the care plan, resulting in a deficiency in providing appropriate mental and psychosocial well-being interventions for the resident.
Failure to Ensure Resident is Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident was as free from unnecessary medications as possible, specifically regarding the use of the antipsychotic medication Seroquel for insomnia. The resident, a 65-year-old with multiple sclerosis and insomnia, was prescribed Seroquel 50 mg for insomnia, an unapproved off-label use. The facility did not follow the gradual dose reduction (GDR) recommendations to reduce the Seroquel dosage from 50 mg to 25 mg, as noted in the psych-pharm management progress notes. Additionally, there was no documentation of consent obtained for the use of Seroquel during the resident's current admission. The social services consultant acknowledged the lack of clinical justification for the off-label use of Seroquel for insomnia and the failure to follow up on the GDR recommendation. The resident's medical record did not provide evidence of a medical justification for the use of Seroquel for insomnia, nor was there documentation of consent for its use during the current admission. The facility's inaction in addressing these issues resulted in the resident being prescribed an unnecessary medication without proper consent or adherence to recommended dosage reductions.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allison Care Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Western Hills Health Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.1 mi | ★★★★★ | 14 | 0 |
| Cambridge Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
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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.