Below 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 Pikes Peak Post Acute during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: A resident with severe dementia, psychotic disturbance, and poor impulse control physically assaulted two other residents, including slapping one resident’s hand and hitting another resident on the back after entering that resident’s room. The record also showed the assaulted residents had severe cognitive impairment and wandering behaviors, and staff observed repeated room entry, touching, taking belongings, and other disruptive behaviors without meaningful redirection. A separate resident with advanced dementia and a pattern of wandering into rooms, becoming combative, and hitting staff was alleged to have pushed another resident, causing a fall and skin tear; the investigation found no witnesses but documented the injury and ongoing aggressive behaviors.
A resident with severe dementia, a BIMS score of 0, wandering, and a communication deficit was repeatedly observed entering other residents’ rooms, touching residents, taking items, and roaming the unit without consistent redirection or meaningful engagement. Although the care plan identified preferences such as magazines, Vietnamese music, snacks, pet visits, and social activities, staff often placed the resident in her room and closed the door or failed to use the communication board, hand gestures, or alternate activities noted in the plan.
The facility failed to document and resolve grievances for several residents, leading to delays and lack of follow-up. Residents reported issues with grievance submissions and follow-ups, including a maintenance issue that remained unresolved. Record reviews showed inconsistencies in grievance documentation and resolution timelines.
The facility did not conduct annual performance reviews or provide in-service education for three CNAs, as required by their policy. The RDCS and new DON acknowledged the absence of these evaluations, which are crucial for determining necessary training. The lack of documentation led to the CNAs not receiving appropriate in-service education.
The facility failed to maintain an effective infection control program, with housekeeping staff not using PPE or performing hand hygiene, and dining areas not being sanitized between meals. Observations showed a housekeeper handling dirty items without gloves and wearing a mask improperly during a flu outbreak. Dining tables and floors were left with debris from previous meals, and staff interviews confirmed these practices were against facility policies.
A resident with paraplegia in an LTC facility did not receive the necessary bed side rails to assist with mobility and independence, despite repeated requests and recommendations from the rehabilitation department. The lack of communication among staff led to the resident's needs being unmet.
A resident with cerebral palsy and other conditions expressed dissatisfaction with her room due to noise from her roommate and neighbor, both with dementia. Despite her cognitive intactness and clear communication of her preference for a room change during a care conference, the facility failed to document or act on her request. The social worker discouraged her from pursuing a formal request, and the social services assistant did not document the concerns, leading to a failure in honoring the resident's right to self-determination.
A resident with a history of aggressive behavior due to Alzheimer's and dementia was involved in two physical altercations with other residents. Despite the facility's policy to protect residents from abuse, there were no new interventions documented in the resident's behavior care plan following these incidents. This oversight contributed to the deficiency in ensuring the safety and protection of residents from abuse.
Two residents in an LTC facility did not receive necessary grooming and hygiene care, including regular showers, nail trimming, and hair washing, despite being dependent on staff for these activities. One resident, with paraplegia and cognitive intactness, had long, dirty fingernails and an unkempt beard, while another resident, with moderate cognitive impairment and hemiplegia, had greasy hair and long nails. Staff interviews confirmed the inconsistency in providing these services due to staffing challenges.
A resident in an LTC facility did not receive new eyeglasses in a timely manner, despite needing them as per an eye consult. The facility's policy requires residents to receive necessary adaptive equipment, but the resident's eyeglasses were missing for several months. The delay was due to a change in vision providers and gaps in the ordering process, as acknowledged by the facility's staff.
A resident with severe cognitive impairments and a history of falls was observed ambulating independently with an unsteady gait and wearing inappropriate footwear, despite requiring assistance or the use of a wheelchair or FWW. Staff failed to provide necessary assistance or encourage the use of the FWW, and the resident was not kept within the line of sight as required by her care plan. The resident experienced multiple falls, resulting in a contusion and a hospital visit, highlighting a lack of adherence to care plan interventions.
The facility failed to maintain a safe and sanitary kitchen environment, with persistent leaks and broken tiles observed over multiple days. The dietary manager was aware of a leak but did not effectively communicate it to maintenance, resulting in unresolved issues. The maintenance director was unaware of the problems until the survey, highlighting a breakdown in communication and procedure adherence.
A resident with dementia and behavioral disturbances repeatedly assaulted other residents due to inadequate intervention and monitoring by the facility staff. Despite being aware of the resident's aggressive tendencies and triggers, the facility failed to implement effective person-centered interventions, leading to multiple incidents of physical abuse. The facility's documentation and investigation of these incidents were insufficient, and staff turnover contributed to the lack of consistent monitoring and intervention.
The facility failed to report multiple incidents of verbal and physical abuse by a resident towards others to the State Survey and Certification Agency, as required by state law. Despite the facility's policy mandating such reports, documentation was lacking, and staff turnover contributed to the oversight. Interviews revealed that the incidents should have been reported, and education was provided to address the reporting process.
A facility failed to investigate multiple incidents of aggression by a resident towards others, including verbal and physical abuse. Despite policy requirements, no investigations were conducted or documented for these incidents. Staff turnover contributed to the oversight, and key personnel acknowledged the deficiency during interviews.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to keep residents free from abuse when it did not prevent resident-to-resident physical abuse involving three residents. The report documents that one resident with severe cognitive impairment, dementia with psychotic disturbance, major depressive disorder, anxiety disorder, and post-traumatic stress disorder was involved in repeated physical aggression toward other residents. The resident had a history of verbal and physical aggression, poor impulse control, and reactivity to environmental stimuli, and the record also showed wandering and territorial behavior. Facility staff and the interdisciplinary team documented that the resident had hit or pushed another resident previously, but the care plan did not fully reflect all of the resident’s altercations. One incident involved the resident slapping another resident’s hand after a verbal escalation. A CNA witnessed the act, and the two residents were separated. The investigation substantiated abuse because the incident was witnessed. The victim had severe cognitive impairment, was dependent on staff for all ADLs, and required supervision or touching assistance for wheelchair mobility. The record also showed that this resident wandered, self-propelled away from the common area, and entered another resident’s room without being redirected during observations. The care plan identified the resident as the recipient of a resident-to-resident altercation and noted wandering and striking out at others if startled or confronted, but the report also documented that the resident did not have physical behavioral symptoms toward others in the MDS. A second incident involved the same aggressive resident wheeling another resident out of her room and hitting her on the back while yelling that the other resident was stealing her things. The other resident had severe cognitive impairment, a communication deficit, and a history of wandering into other residents’ rooms and taking their belongings. Observations showed this resident repeatedly entering other residents’ rooms, touching residents, digging through trash, taking items, and moving through the unit without meaningful staff intervention. Staff and the care plan documented that she would go into others’ rooms and grab others to get attention, but the report states staff failed to intervene and provide meaningful redirection during the observed behaviors. The facility also failed to protect another resident from physical abuse by a different resident with advanced dementia and a documented pattern of wandering into rooms, lying in other residents’ beds, becoming combative when redirected, and hitting or kicking staff. On the incident date, the victim reported that the resident pushed her, causing her to fall and sustain a skin tear to her forearm. The investigation found no witnesses and concluded the event was unsubstantiated, but the documentation showed a new skin tear consistent with the allegation. The assailant’s record showed repeated room entry, aggression, and escalating behaviors toward staff and residents before and after the incident, while the victim had moderate cognitive impairment and no documented behavioral symptoms toward others.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to ensure that a resident with severe dementia and a BIMS score of 0 received appropriate, person-centered treatment and services to support the highest practicable physical, mental, and psychosocial well-being. The resident had diagnoses including severe dementia with behavioral disturbances and cognitive communication deficit, and the record showed care plans for wandering, grabbing others, taking items from other residents’ rooms, limited English, and elopement risk. Interventions in the care plan included redirecting the resident from other residents’ rooms, offering alternate objects or activities, using a communication board, and encouraging participation in activities. Observations showed the resident repeatedly entered other residents’ rooms, touched residents, took items, opened doors, and wandered throughout the unit without consistent staff intervention. Staff were observed taking the resident back to her room and closing the door without speaking to her, rather than providing meaningful redirection or distraction. At other times, staff walked past the resident while she attempted to open doors, touched another resident, or disrupted other residents’ spaces, and no intervention was made to redirect her. The resident was also observed turning off lights, eating crumbs from her wheelchair cushion, pulling on a radio cord near an outlet with exposed wiring, and moving through the dining room and common areas without effective engagement. Record review and interviews showed the facility knew the resident enjoyed reading magazines, Vietnamese music, pet visits, snacks, dogs, and social groups, and staff stated she was very tactile and liked to touch things. Staff also acknowledged that residents with communication deficits should be approached with hand gestures, communication boards, and redirection, and that the resident should not be placed in her room and have the door closed as an intervention for wandering. Despite this, survey observations showed the resident was not consistently redirected, her preferences were not consistently offered, and the communication board was not used with her.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain an effective system for documenting and resolving grievances for four residents. During a group interview, residents expressed concerns about the lack of follow-up on grievances they had submitted. One resident mentioned not receiving any feedback on grievances submitted to social services, while another resident reported that formal grievance forms were submitted without any follow-up from staff. A third resident, who required assistance due to visual deficits, experienced delays and difficulties in having grievances documented and addressed. Additionally, a resident reported a maintenance issue that was not resolved, as evidenced by an observed clog in the bathroom sink. A review of facility records revealed that grievances were not consistently documented or resolved in a timely manner. For instance, a grievance related to oxygen and medication administration was not addressed with the resident for over 30 days. Another grievance concerning dietary issues was signed by a registered dietitian consultant instead of the resident. Furthermore, there were no records of grievances for two residents, despite their claims of having submitted them. Interviews with the Social Services Director indicated that staff were expected to assist residents with grievances and provide timely follow-up, but this process was not effectively implemented.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews and provide regular in-service education for three certified nurse aides (CNAs), as required by their policy. The policy, revised in September 2020, mandates that each employee's job performance be reviewed at least annually, with evaluations completed at the end of a 90-day probationary period and annually thereafter. However, the facility was unable to provide the required performance evaluations for 2024 for CNA #4, CNA #5, and CNA #6, indicating a lapse in adherence to their own procedures. Interviews with the regional director of clinical services (RDCS) and the director of nursing (DON) revealed that the facility did not have the performance reviews for the CNAs in question. The RDCS acknowledged the importance of these evaluations for conducting appropriate in-service training. The DON, who was new to her role, admitted to not knowing where the former DON kept the staff records, which contributed to the oversight. This lack of documentation and follow-through on performance evaluations resulted in the CNAs not receiving the necessary in-service education based on their performance reviews.
Infection Control Deficiencies in Housekeeping and Dining Areas
Penalty
Summary
The facility failed to maintain an effective infection control program across three of its nine units, as evidenced by several observations and interviews. Housekeeping staff did not adhere to the facility's policy on using personal protective equipment (PPE) and performing hand hygiene. Specifically, a housekeeper was observed cleaning residents' rooms without wearing gloves, handling dirty mopheads and trash with bare hands, and failing to sanitize her hands afterward. Additionally, the housekeeper was seen wearing a mask improperly during a flu outbreak, with the mask positioned under her nose. The facility also failed to ensure that dining tables and floors were sanitized between meals. Observations revealed that dining tables in the 100 hallway dining room were left with crumbs, beverage stains, and other debris from previous meals. Despite the presence of residents waiting for meals, the tables and floors were not cleaned before the next meal service. This lack of sanitation was consistent over several days, as noted by the surveyors. Interviews with staff, including the housekeeping supervisor and the infection preventionist, confirmed that the observed practices were not in line with the facility's infection control policies. The dietary manager acknowledged that dietary aides were responsible for cleaning the dining room tables and serving areas but admitted there was no cleaning log for the 100 hallway dining room. A resident also reported that the dining room was often not cleaned after meals, corroborating the surveyors' findings.
Failure to Provide Necessary Bed Side Rails for Resident with Paraplegia
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with paraplegia, who required bed side rails to assist with mobility and independence. Despite the resident's repeated requests for side rails since admission, and recommendations from the rehabilitation services department, the facility did not install the side rails. The resident, who was cognitively intact, expressed that the absence of side rails limited her independence and ability to reposition herself in bed. Interviews with staff, including registered nurses, certified nurse aides, and therapy personnel, confirmed that the resident's need for side rails was known but not acted upon. The assistant director of rehabilitation was unaware of the request, and the director of nursing was not informed of the resident's needs or the therapy department's recommendations. This lack of communication resulted in the resident not receiving the necessary accommodations to support her mobility and independence.
Failure to Honor Resident's Room Change Request
Penalty
Summary
The facility failed to honor a resident's choice regarding her room assignment, which is a violation of the resident's right to self-determination. The resident, who is under 65 and has cerebral palsy, scoliosis, hip pain, and depression, was cognitively intact and expressed dissatisfaction with her current room situation. She was disturbed by the noise from her roommate and a neighbor, both of whom had dementia-related behaviors. Despite her clear communication of these concerns during a care conference, there was no documentation or follow-up from the social services department. The facility's policy on Resident Self-Determination and Participation emphasizes the importance of respecting and promoting residents' autonomy, including their choice of roommates. However, the resident reported that the social worker discouraged her from formally requesting a room change, suggesting she might end up with a worse roommate. This lack of support and documentation from the social services department contributed to the facility's failure to facilitate the resident's preference for a room change. Interviews with the social services director revealed that the social services assistant failed to document the resident's concerns during the care conference, leaving the director unaware of the resident's request for a room change. The director acknowledged the importance of documenting such concerns and following up to ensure residents receive appropriate care. The deficiency was identified when the resident's request for a room change was not addressed, despite her participation in the care conference and her expressed need for a quieter environment.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving physical altercations initiated by one resident against two others. Resident #144, who has a history of aggressive behavior due to Alzheimer's disease and dementia, was involved in two separate incidents of physical abuse against Resident #88 and Resident #54. In the first incident, Resident #144 entered Resident #88's room and allegedly hit him multiple times, although no physical injuries were observed on Resident #88. Despite the facility's policy to protect residents from abuse and implement measures to prevent such incidents, there were no new interventions documented in Resident #144's behavior care plan following this altercation. In the second incident, Resident #144 was involved in a physical altercation with Resident #54. The facility's investigation revealed that Resident #144 entered Resident #54's room and hit her, although she reported no injuries. The facility's investigation was ongoing at the time of the report, and Resident #144 was placed on one-to-one monitoring. However, similar to the first incident, there were no new interventions documented in Resident #144's behavior care plan to prevent further altercations. The facility's failure to update Resident #144's behavior care plan with new interventions after each incident indicates a lack of adequate measures to prevent further resident-to-resident altercations. Despite the facility's awareness of Resident #144's aggressive behaviors and the potential for harm to other residents, the care plan did not reflect any changes to address these issues effectively. This oversight contributed to the deficiency in ensuring the safety and protection of residents from abuse.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, specifically in the areas of grooming and personal hygiene. Resident #48, who is cognitively intact and dependent on staff for all ADLs due to conditions such as paraplegia and emphysema, did not receive regular grooming services. Observations revealed that the resident had long, jagged fingernails with brown matter underneath, greasy and uncombed hair, and an unkempt beard, despite expressing a preference for regular showers and shaves. The resident's care plan did not include provisions for shaving or nail care, and the bathing record showed infrequent showers without documentation of nail trimming or beard shaving. Resident #77, who has moderate cognitive impairment and requires assistance with ADLs due to conditions like hemiplegia and contractures, also did not receive adequate grooming care. The resident's hair was observed to be dirty and greasy, and her fingernails were long with brown matter underneath. Despite preferring short nails and regular hair washing, the resident reported that staff were too busy to offer these services consistently. The care plan for this resident did not include specific instructions for bathing or nail care, and the bathing record indicated infrequent bed baths without documentation of hair washing or nail trimming. Interviews with staff, including the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), confirmed the lack of consistent grooming care for these residents. The DON acknowledged the importance of regular showers and grooming to prevent skin infections and maintain hygiene but noted staffing challenges following the departure of a dedicated shower aide. The facility's policy requires that residents who cannot perform ADLs independently receive necessary services, but this was not consistently implemented for the residents in question.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for a resident, resulting in a deficiency. The resident, an 83-year-old with dementia and other health conditions, required eyeglasses as per an eye consult. Despite this need, the resident's new eyeglasses were not obtained in a timely manner. The facility's policy mandates that residents receive necessary adaptive equipment, but the resident's representative reported that the eyeglasses had been missing for several months, and inquiries about their status were not adequately addressed by the facility. The delay in obtaining the eyeglasses was attributed to a change in vision providers and gaps in the ordering process, as acknowledged by the facility's social services director and regional director of clinical services. The social services director, responsible for ensuring the resident received the eyeglasses, admitted to being behind on residents' ancillary needs. The director of nursing confirmed that the eyeglasses were only ordered during the survey, indicating a significant lapse in the facility's process to provide necessary vision services to the resident.
Inadequate Supervision and Care Plan Adherence Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plan interventions for a resident, leading to multiple falls. The resident, over 65 years old, with severe cognitive impairments and a history of falls, was observed ambulating independently with an unsteady gait and wearing sock-like slippers, despite requiring hands-on assistance or the use of a wheelchair or four-wheel walker (FWW) as per her care plan. Staff members, including a registered nurse and certified nurse aide, did not provide the necessary assistance or encourage the use of the FWW, and the resident was not kept within the line of sight as required by her care plan. The resident's care plan, revised in October 2024, included interventions such as using non-skid socks or footwear, keeping the resident within sight, and encouraging the use of a wheelchair or FWW. Despite these interventions, the resident was observed multiple times ambulating without assistance and wearing inappropriate footwear. The resident had a history of falls, with incidents occurring on January 14 and January 20, 2025, resulting in a contusion and a hospital visit. The facility's staff failed to implement the care plan interventions effectively, as evidenced by the resident's continued unassisted ambulation and inappropriate footwear. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. The registered nurse acknowledged the resident's tendency to assist other residents and the need to keep her within sight, but did not ensure the resident used her walker. The certified nurse aide incorrectly believed the resident could ambulate independently. The director of nursing was unaware of the resident's inappropriate footwear and the lack of encouragement for walker use, indicating a breakdown in communication and implementation of care plan interventions.
Failure to Maintain Safe and Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functional kitchen environment, as observed during a survey. On multiple occasions, surveyors noted a persistent leak from the kitchen employee's hand washing sink, a leak from a pipe under the three-compartment dishwashing sink, and broken floor tiles floating on accumulated water. These issues were not addressed promptly, as evidenced by the lack of change in conditions over two days of observations. The dietary manager (DM) was aware of the leak under the dishwashing sink for at least a week but had not effectively communicated this to the maintenance department, as no work order was submitted until the survey was conducted. Interviews with staff revealed a breakdown in communication and procedure adherence. The DM admitted to knowing about the leak under the dishwashing sink but could not recall notifying maintenance. The maintenance director (MTD) was unaware of the issues until the survey and had not received any work orders from the DM. The MTD identified the cause of the leak under the hand washing sink as a disconnected drain pump from an adjacent ice machine. Despite having a system in place for reporting maintenance issues, the facility's staff failed to utilize it effectively, leading to unresolved maintenance problems in the kitchen.
Failure to Prevent Resident Abuse Due to Inadequate Intervention
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to address the physically aggressive behavior of a resident with dementia and behavioral disturbances. This resident, who had a history of physical aggression, assaulted another resident on multiple occasions. Despite being aware of the resident's territorial nature and aversion to being touched, the facility staff did not intervene in a timely manner to prevent these incidents. The facility's policy required monitoring and intervention for aggressive behaviors, but these measures were not effectively implemented. The aggressive resident was prescribed medications for agitation and behavioral disturbances, and his care plan included interventions such as redirection and de-escalation. However, these interventions were not consistently applied, leading to repeated incidents of physical abuse. The facility's documentation and investigation of these incidents were inadequate, with several instances of abuse not being properly investigated or reported. The facility's failure to implement person-centered interventions and monitor the resident's behavior contributed to the ongoing abuse. Interviews with facility staff revealed that there was a lack of consistent monitoring and intervention for the aggressive resident. The staff acknowledged the resident's triggers and the need for close supervision, but these measures were not consistently enforced. The facility also experienced turnover in key positions, which may have contributed to the lack of follow-through in addressing the resident's behavior. The facility's management did not adequately review progress notes to identify and address potential triggers for aggressive behavior, resulting in missed opportunities to prevent further abuse.
Failure to Report Abuse Incidents to State Agency
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency (SSA) as required by state law for three residents. Specifically, incidents involving a resident's verbal and physical abuse towards other residents were not reported. On one occasion, a resident verbally abused another resident in the dining room, and the staff failed to document this incident to the SSA. Additionally, the same resident physically abused another resident by shoving her into a wall, causing her to hit her head, yet this incident was also not reported. Another incident involved the same resident attempting to kick and hit another resident, which again was not reported to the SSA. The facility's policy requires all reports of resident abuse, neglect, exploitation, or theft to be reported to local, state, and federal agencies and thoroughly investigated. However, the facility was unable to provide documentation that these incidents were reported. Interviews with the clinical consultant and the director of nursing revealed that there was a lack of abuse investigations due to recent turnover in key positions, and some incidents were not reported to the SSA. The clinical consultant acknowledged that the incidents involving the resident should have been reported and provided education to the nursing home administrator on the process of reporting abuse.
Failure to Investigate Resident Aggression Incidents
Penalty
Summary
The facility failed to investigate multiple incidents of physical and verbal aggression involving a resident, leading to a deficiency in handling alleged violations. The facility's policy requires all altercations, including those that may represent resident-to-resident abuse, to be investigated and reported to the nursing supervisor, the director of nursing services, and the administrator. However, the facility did not conduct investigations for several incidents involving a resident's aggressive behavior towards other residents. These incidents included verbal abuse towards one resident and physical abuse towards another resident on the same day, as well as further physical aggression on two separate occasions. The facility was unable to provide documentation of investigations for these incidents when requested during the survey process. Interviews with the clinical consultant and the assistant director of nursing revealed that there had been turnover in key positions, which contributed to the lack of investigations. The clinical consultant acknowledged that the incidents should have been investigated and reported, but the facility did not have a sufficient number of abuse investigations on record. The assistant director of nursing confirmed that she had reported one of the incidents to the director of nursing and the nursing home administrator, but no further action was documented.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Rehabilitation And Nursing, Llc | 0.6 mi | ★★★★★ | 3 | 0 |
| Sunny Vista Living Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Springs Village Care Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Medallion Post Acute Rehabilitation | 2.4 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Colorado Springs | 2.7 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.