Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hazelhurst Court Care And Rehabilitation Center during CMS and state inspections, most recent first.
Food items were found improperly labeled, undated, and in some cases expired during a kitchen tour with the Dietary Mgr. Surveyors observed opened and unlabeled frozen items, undated pantry items, and multiple opened prep-station items that lacked open dates or had expired dates. The Dietary Mgr confirmed all findings and stated she was responsible for ensuring food was labeled with open and expiration dates.
Uncleaned Dryer Lint Trap: During an observation, the lint filter of the second dryer near the window was found not cleaned. The ESD stated lint traps must be cleaned after each use or at least every hour with documentation, and confirmed the dryer lint trap had not been cleaned per facility policy. The ESD also stated that unclean lint filters could cause a fire.
A facility failed to notify a resident and/or her representative when trust fund balances were within $200 of the SSI limit and when the account exceeded the $2,000 cap. The resident had severe cognitive impairment with a BIMS of 5 and diagnoses including dementia, while staff interviews showed the VP of Revenue Cycle Management, receptionist, and Social Services did not ensure written financial notices were sent to the family representative, who said she never received any financial statements or notices.
A facility failed to follow care plans for two residents. One resident with diabetes, reduced mobility, and personal care needs had long, untrimmed fingernails with debris under the nail beds despite a care plan directing nail care on scheduled bath days. Another resident with acute chronic respiratory failure with hypoxia had a physician order for O2 at 2 L/min via NC, but the care plan and staff interview showed the setting was incorrect.
Failure to Provide Nail Care for a Resident Needing ADL Assistance: A resident with type 1 DM, reduced mobility, and dependence on staff for ADLs was observed with long, untrimmed fingernails and visible brown debris under the nail beds. The resident was scheduled for bath days, had no documented refusal of hygiene care, and staff including a CNA, LPN, DON, and RN UM confirmed the nail condition and that nurses and CNAs were responsible for nail care, with nurses trimming nails for residents with diabetes.
A resident with acute chronic respiratory failure with hypoxia, SOB, and oxygen therapy orders was observed receiving oxygen via nasal cannula at 1.5 LPM instead of the ordered 2 LPM. The DON confirmed nurses were responsible for checking the setting during med pass and rounding, and later stated the concentrator was faulty and the rate was off by a half liter.
A resident with multiple medical conditions and a documented Full Code status was not provided CPR when found unresponsive, despite clear physician orders and care plan directives. Nursing staff did not attempt resuscitation, mistakenly believing that hospice admission changed the code status to DNR, even though the POLST and care plan specified Full Code. This deficiency was confirmed during staff interviews and record review.
A resident with full code status and clear physician orders to attempt CPR was found unresponsive and not breathing. Despite facility policy and documentation specifying to initiate CPR, staff did not attempt resuscitation, mistakenly believing that hospice enrollment implied DNR status. Multiple staff, including LPNs and CNAs, failed to verify the resident's code status or provide life-sustaining measures, resulting in the deficiency.
Nursing administration did not ensure that staff followed a resident's Full Code advance directive, resulting in no CPR being attempted when the resident was found unresponsive. Despite clear documentation and confirmation from the responsible party that the resident was to remain Full Code, staff incorrectly assumed hospice status meant DNR, leading to the deficiency.
The facility failed to provide residents with appealing meal options, offering only sandwiches or soup as alternatives if residents disliked the meal served. During a Resident Council meeting, residents expressed dissatisfaction with the lack of alternate meal choices. The facility's menu did not include alternate meal options, and staff interviews confirmed the absence of hot entrees as alternatives. A resident reported never having a choice of meals, and observations confirmed the lack of alternate meals during service. The Administrator acknowledged the issue but stated that residents could receive a grilled cheese sandwich if requested.
The facility did not follow its food storage policy, resulting in expired food items being found in the stand-up cooler during a kitchen tour. The Dietary Manager confirmed and discarded the expired sliced ham and chicken and noodles, acknowledging the expectation for staff to dispose of items before expiration. This oversight potentially affected 50 of 53 residents on an oral diet, posing a risk of illness.
A facility failed to follow infection control protocols during tracheostomy care for a resident with multiple diagnoses, including tracheostomy status. RN AA did not perform hand hygiene after glove changes, and soiled items were improperly disposed of, increasing the risk of infection. Staff interviews revealed a lack of in-service training for LPN CC, and the DON confirmed expectations for proper hand hygiene and glove changes.
The facility failed to maintain a clean environment in a resident's room, as a privacy curtain was found with a brown stain and white chalky substance. Despite the facility's policy for monthly deep cleaning, Room 33 was not cleaned in January or February 2025. Interviews revealed that the housekeeper did not notice the soiled curtain, and the Administrator confirmed the expectation for staff to follow cleaning protocols.
A facility failed to provide a written reason for transfer to a resident or their representative, as required by policy. Despite the policy mandating written notification, staff interviews revealed that the facility only provided verbal communication. This inconsistency with policy led to a deficiency being identified during the survey.
A facility failed to provide a written bed hold notice to a resident's representative during hospital transfers, contrary to its policy. Despite the policy requiring written notification within 24 hours of an emergency transfer, staff interviews revealed that the facility only verbally informed the representative, assuming the resident would return. An unsigned bed hold agreement was found in the resident's record.
The facility failed to follow care plans for oxygen administration for three residents, leading to discrepancies between physician orders and actual care provided. One resident with COPD received oxygen at a higher rate than ordered, while another with acute respiratory failure did not receive the prescribed oxygen via trach collar. The MDS Coordinator and DON confirmed these failures, highlighting a lack of adherence to the facility's care planning policy.
The facility failed to follow physician orders for oxygen administration for three residents, leading to incorrect oxygen flow rates. A resident with COPD received 7 liters per minute instead of 3, another with COPD received 3 liters instead of 2, and a resident with acute respiratory failure received 5 liters instead of 4. LPNs admitted to not checking the oxygen settings during medication pass, contrary to the DON's expectations.
Food Items Left Open, Undated, and Expired
Penalty
Summary
The facility failed to ensure food was properly labeled, dated, and maintained in sanitary conditions in accordance with the policy titled Food Storage. During a tour with the Dietary Manager, surveyors observed multiple food items in the freezer that were opened and not labeled, including a large bag of broccoli and a box of frozen cinnamon rolls, along with two packs of dumplings and a pack of spinach that were past the expiration date. In the pantry, four boxes of lasagna and one gallon jug of Worcestershire sauce were not dated. In the kitchen at one of the prep stations, surveyors observed five opened seasoning containers, pancake and waffle syrup, two cans of cooking spray, a gallon bottle of barbeque sauce, two bottles of lemon juice, a bag of brownie mix with an expired date, a bag of corn meal mix, a container of salt with an expired date, and a jar of mayonnaise that were opened and/or not dated. The Dietary Manager confirmed all of the surveyor's identified concerns and stated she was responsible for ensuring food was labeled with open and expiration dates.
Uncleaned Dryer Lint Trap
Penalty
Summary
The facility failed to ensure adherence to established laundry maintenance protocols related to dryer lint trap cleaning. During an observation on 03/28/2026 at 8:40 AM, the lint filter of the second dryer located near the window was observed not to have been cleaned. During an interview on 03/28/2026 at 10:52 AM, the Environmental Services Director stated that lint traps are required to be cleaned after each use or, at a minimum, every hour, with staff required to document completion, and confirmed that the lint trap in the second dryer had not been cleaned in accordance with facility policy. The Environmental Services Director also confirmed that if the lint filters are not cleaned it could cause a fire.
Failure to Notify Resident and Representative of Trust Fund Balance Limits
Penalty
Summary
The facility failed to notify the resident and/or the resident’s responsible party when personal funds were within $200 of the SSI limit and when the account balance exceeded the allowable amount. Facility policy titled Resident Trust Fund stated that Medicaid recipients must be notified whenever their funds are within $200 of their resource asset limit and that balances should be monitored monthly to ensure state maximum balances are not exceeded. Review of the Resident Statement Landscape report showed that R45’s trust fund accounts exceeded the $2,000 SSI limit for 12 months, from February 2025 through February 2026. R45’s record showed diagnoses including dementia in other diseases classified elsewhere, severe without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and dementia, mild, with agitation. The quarterly MDS documented a BIMS score of 5, indicating severe cognitive impairment. Interviews revealed the VP of Revenue Cycle Management was handling resident accounts after the BOM position was vacant and admitted she had not followed up with the Medicaid Eligibility Officer about R45’s account being over $2,000 for the last 12 months. The receptionist stated she was responsible for notifying residents and/or representatives when accounts reached within $200 of $2,000, but she had not sent written notifications to R45’s representative since June 2025 and had only given notices to R45. R45’s family representative stated she had never received any financial notices or statements from the facility, and Social Services stated she contacted the representative about spending down the account by prepaying burial/funeral arrangements but did not notify her that the account was over $2,000.
Failure to Follow Care Plan for Nail Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident with diagnoses including type 1 diabetes mellitus with hyperglycemia, reduced mobility, and need for assistance with personal care. The care plan, initiated 12/25/2025, directed staff to assist with bathing as needed per the resident schedule, monitor skin during bathing, and have the nurse assist with nail care on scheduled bath days and as needed. The resident was scheduled for baths on Monday, Wednesday, and Friday on night shift, but observations on 03/27/2026 and 03/28/2026 showed long, untrimmed fingernails with visible debris and a brown substance under the nail beds. During observations and interviews, a CNA, an LPN, and another CNA confirmed the condition of the resident’s fingernails, and the LPN stated that nurses and CNAs were responsible for nail care. The facility also failed to follow the care plan for a resident with acute chronic respiratory failure with hypoxia. Physician orders dated 02/14/2026 directed oxygen at 2 liters per minute via nasal cannula, but the care plan listed the diagnosis and included interventions that did not reflect the ordered oxygen setting. During interview, the MDS Coordinator stated that the physician order was for oxygen to be set at 2 liters per minute and confirmed that 1.5 liters per minute was the wrong setting. The MDS Coordinator also stated that staff were expected to follow the care plan.
Failure to Provide Nail Care for a Resident Needing ADL Assistance
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who was unable to perform activities of daily living independently. R28 had diagnoses including type 1 diabetes mellitus with hyperglycemia, other reduced mobility, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 7, no rejection of care, and dependence on staff for ADL care. The facility’s policy stated that nail care includes daily cleaning and regular trimming, with diabetic residents’ nail trimming done per MD order, and podiatry care scheduled as needed for residents with identified podiatry needs. R28 was scheduled for bathing on Monday, Wednesday, and Friday nights, and the facility’s documentation survey report from January 2026 through March 2026 showed no refusal of ADL bathing or personal hygiene related to nail care. However, during multiple observations, R28 was seen with long, untrimmed fingernails and visible debris containing a brown substance underneath the nail beds. A CNA, an LPN, the DON, and the RN Unit Manager all confirmed the condition of the resident’s fingernails. The LPN stated that nurses and CNAs were responsible for nail care, the DON stated staff were expected to provide nail care on bath days as scheduled, and the RN Unit Manager stated CNAs were responsible for nail care and nurses were responsible for trimming the nails of residents with diabetes.
Oxygen Flow Rate Not Set as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for R31, who had diagnoses including acute chronic respiratory failure with hypoxia. The resident’s MDS indicated a BIMS of 7, shortness of breath, and receipt of oxygen therapy. Physician orders dated 02/14/2026 directed oxygen at 2 liters per minute via nasal cannula, and the facility policy for Respiratory System Management directed staff to check the physician’s orders and turn the flow meter to the ordered flow rate. Observations on 03/27/2026 and 03/28/2026 showed R31 lying in bed receiving oxygen via nasal cannula at 1.5 liters per minute instead of the ordered 2 liters per minute. During rounding with the DON, the DON confirmed nurses were responsible for ensuring the oxygen setting matched the prescribed rate during medication pass and rounding and verified the rate should have been 2 liters per minute. An LPN confirmed the order was for 2 LPM and stated she had not checked R31’s oxygen as of the time of interview. The DON later stated she found the oxygen rate off by a half liter because the concentrator was faulty and was unsure how long it had been broken.
Failure to Implement Advanced Directive Care Plan for Full Code Resident
Penalty
Summary
The facility failed to implement the Advanced Directive care plan for a resident who was designated as Full Code, resulting in CPR not being performed when the resident was found without a pulse or respirations. The resident had a documented history of cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. The clinical record, physician's orders, and care plan all specified that the resident was to be a Full Code and that resuscitation (CPR) should be attempted. The resident was also admitted to hospice services, but the POLST form and care plan continued to specify Full Code status. On the day of the incident, staff discovered the resident deceased and documented the absence of pulse and respirations, but there was no evidence that CPR was attempted as required by the care plan and physician's orders. Interviews with staff, including the DON, revealed a misunderstanding among nursing staff, who believed that hospice admission automatically changed the resident's code status to DNR, despite clear documentation to the contrary. The deficiency occurred during a shift change, and the DON confirmed that no resuscitation efforts were made.
Failure to Initiate CPR for Full Code Resident Due to Staff Misunderstanding
Penalty
Summary
Facility staff failed to assess and implement life-sustaining measures for a resident who was found unresponsive, despite the resident's advanced directives and physician orders specifying full code status and to attempt CPR. The facility's Emergency Response Management and Cardiopulmonary Resuscitation (CPR) policies required staff to initiate CPR in the event of cardiac or respiratory arrest for residents with full code status. The resident, who had diagnoses including cerebral atherosclerosis and was receiving hospice services, had a current POLST form and physician's order indicating that CPR should be attempted. On the day of the incident, the resident was noted by a CNA to be cold and not feeling well, and this was reported to the assigned LPN. Later, when the CNA returned to check on the resident, she found the resident cold and called for help. Multiple staff, including CNAs and LPNs, became aware that the resident was unresponsive and had no pulse or respirations. However, none of the nurses present checked the resident's code status or initiated CPR, as required by the resident's directives and facility policy. The DON later confirmed that staff mistakenly believed that hospice status implied a Do Not Resuscitate (DNR) order, despite documentation to the contrary. Interviews with staff revealed confusion during the shift change, with day and night shift nurses deferring responsibility to each other and not responding to the resident's room when alerted. The night shift LPN, upon being notified by a CNA, assessed the resident and confirmed the absence of vital signs but did not attempt CPR or verify code status. The failure to initiate CPR was not due to lack of policy or documentation, but rather staff assumptions and lack of verification regarding the resident's code status.
Failure to Honor Advance Directive for Full Code Resident
Penalty
Summary
Facility nursing administration failed to provide effective oversight to ensure that nursing staff assessed and implemented the correct Advance Directive for one of eleven sampled residents reviewed for Advance Directives. The resident, who had diagnoses including cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia, was admitted to hospice services but maintained a Full Code status as specified in both the physician's order and the updated POLST form. The resident's responsible party also confirmed the desire for Full Code status. Despite these clear directives, when the resident was found without a pulse or respirations, there was no evidence that CPR was attempted by facility staff. Interviews with the DON revealed that nursing staff mistakenly believed that hospice admission automatically meant Do Not Resuscitate (DNR) status, leading to the failure to initiate CPR. The incident occurred during a shift change, with both day and night shift nurses present in the facility. The DON confirmed that the staff were already notifying hospice when she arrived at the resident's room and that she was later informed by staff that the resident was a Full Code. Documentation and staff interviews confirmed that the resident's wishes for resuscitation were not honored at the time of death.
Lack of Alternate Meal Options for Residents
Penalty
Summary
The facility failed to provide residents with appealing meal options that accommodate their preferences, as required by their policy. During a Resident Council meeting, residents expressed dissatisfaction with the lack of alternate meal choices, stating that if they did not like the meal served, their only options were a sandwich or soup. The facility's fall/winter menu did not include alternate meal choices for lunch or dinner, and interviews with dietary staff confirmed that no alternate hot entrees were available. The Registered Dietician acknowledged the absence of alternate meal options and attributed it to budget constraints, noting that no alternate menus had been requested from the vendor. One resident, who had been at the facility for a year, reported never having a choice of meals and not being offered an alternate meal if she disliked the one served. Observations during the survey confirmed the absence of alternate meals on the menu and the hot steam tray unit during meal service. Interviews with the Dietary Manager, Dietary Aids, and the Administrator revealed a consistent practice of offering only sandwiches or soup as alternatives, with no hot meal options available. The Administrator was aware of the issue but stated that residents could receive a grilled cheese sandwich if requested.
Expired Food Items Found in Facility's Stand-Up Cooler
Penalty
Summary
The facility failed to adhere to its food storage policy, which mandates that leftover food be stored in covered containers, clearly labeled, dated, and used within 48 hours or discarded. During a kitchen tour, surveyors observed expired food items in the stand-up cooler, including a resealable plastic bag of sliced ham and a plastic container of chicken and noodles, both past their expiration dates. The Dietary Manager confirmed the presence of these expired items and discarded them, acknowledging that the expectation was for staff to dispose of items before they expire. This oversight had the potential to affect 50 of the 53 residents receiving an oral diet, posing a risk of illness to the residents.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during tracheostomy care for a resident with multiple diagnoses, including tracheostomy status and acute respiratory failure. During an observation, it was noted that RN AA did not perform hand hygiene after donning and doffing gloves throughout the tracheostomy care procedure, which is a deviation from the facility's policy. Additionally, RN AA placed soiled towels in a yellow plastic trash bag and left it on the floor for two hours, which is not in line with proper disposal practices. The resident involved was non-verbal and had a tracheostomy in place, secured with ties, and was receiving oxygen via a trach collar. Interviews with the staff revealed that LPN CC, who assisted with the procedure, had not received in-service training on tracheostomy care, and RN AA acknowledged the failure to wash hands as required. The Director of Nursing confirmed the expectation for hand hygiene and glove changes during the procedure, and LPN BB later removed the improperly placed trash bag from the floor.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in Room 33, as evidenced by the presence of a brown stain and a white chalky substance on the privacy curtain. Observations were made on three separate occasions, confirming the deficiency. The facility's cleaning schedule indicated that Room 33 was not deep cleaned in January or February 2025, despite the facility's policy requiring monthly deep cleaning of each resident's room, including checking and replacing soiled privacy curtains. Interviews with the housekeeping staff and the Account Manager revealed that the facility has a five-step daily cleaning process and a seven-step deep cleaning process, both of which include checking the curtains for stains. However, the housekeeper responsible for cleaning Room 33 admitted to not noticing the soiled curtains during her cleaning routine. The Administrator confirmed that the housekeeping staff is expected to follow these cleaning steps to ensure a clean environment for residents.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written reason for transfer to a resident or their representative, as required by their policy. The policy, dated February 2015, mandates that the resident or their family/responsible party be notified in writing of a transfer, except in cases of unplanned, acute clinical needs where verbal communication is followed by written documentation in the medical record. However, for a resident with unspecified dementia and type 2 diabetes mellitus with hyperglycemia, there was no evidence of a written reason for transfer provided to the resident's representative during two hospitalizations. Interviews with facility staff, including LPNs and the Business Officer Manager, revealed that the facility's practice was to verbally notify the family or representative of the reason for transfer but not to provide written documentation. The Director of Nursing confirmed that no written notification was given because the facility expected the resident to return. This practice was inconsistent with the facility's policy and resulted in a deficiency being identified during the survey.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident's representative during two separate hospital transfers. The facility's policy, revised on 3/3/2020, mandates that a copy of the bed hold agreement be provided to the resident or responsible party prior to a transfer or within 24 hours in case of an emergency transfer. However, for a resident with diagnoses including unspecified dementia and type 2 diabetes mellitus, there was no evidence of a bed hold notice being provided during hospital transfers on 5/13/2024 and 12/18/2024. An unsigned bed hold agreement was found in the resident's record for the latter date. Interviews with facility staff revealed a lack of adherence to the policy. An LPN stated that while a document including a bed hold agreement is completed and given to emergency medical services, it is not provided to the resident or their representative. The Business Officer Manager confirmed that the facility only calls the family representative to notify them of the bed hold agreement, without providing written documentation. The Director of Nursing also verified that no written notice is given to the representative, as the facility assumes the resident will return.
Failure to Follow Oxygen Administration Care Plans
Penalty
Summary
The facility failed to adhere to the care plans for three residents regarding oxygen administration, as observed and confirmed through record reviews and staff interviews. Resident 12, diagnosed with COPD and hypoxemia, was observed receiving oxygen therapy at 7 liters per minute, contrary to the physician's order of 3 liters per minute. This discrepancy was confirmed by both the LPN and the Director of Nursing, who acknowledged the failure to follow the care plan. Similarly, Resident 7, with a diagnosis of COPD, had a physician's order for oxygen at 2 liters per minute as needed, but the care plan was not followed as verified by the MDS Coordinator. Resident 14, diagnosed with acute respiratory failure, was supposed to receive oxygen at 4 liters per minute via trach collar according to the physician's order. However, the care plan was not adhered to, as confirmed by the MDS Coordinator and the DON. The facility's policy on care planning management was not effectively implemented, leading to these deficiencies in care. The MDS Coordinator and the DON both expressed expectations that staff should follow the care plans, which clearly outlined the required oxygen administration for each resident.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration for three residents, leading to a deficiency in respiratory care. Resident 12, diagnosed with COPD and hypoxemia, was observed receiving oxygen therapy at 7 liters per minute, contrary to the physician's order of 3 liters per minute. Licensed Practical Nurse EE admitted to not checking the oxygen settings during medication pass, which is when the settings should have been verified. The Director of Nursing (DON) confirmed that staff are expected to ensure oxygen is administered as ordered. Similarly, Resident 7, with a diagnosis of COPD, was receiving oxygen at 3 liters per minute instead of the prescribed 2 liters per minute. LPN BB acknowledged the oversight in checking the oxygen rate during the morning medication pass. Resident 14, diagnosed with acute respiratory failure, was receiving oxygen at 5 liters per minute via trach collar, instead of the ordered 4 liters per minute. LPN BB again admitted to not verifying the oxygen rate as per the physician's order. The DON reiterated the expectation that oxygen settings should be checked during medication pass, as oxygen is considered a medication.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hazlehurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woods At Lumber City Of Journey Llc, The | 10.6 mi | ★★★★★ | 8 | 0 |
| Appling Nursing And Rehabilitation Pavilion | 16.1 mi | ★★★★★ | 0 | 0 |
| Mcrae Manor Nursing Home | 22.1 mi | ★★★★★ | 11 | 0 |
| Glenwood Health And Rehabilitation | 22.2 mi | ★★★★★ | 22 | 0 |
| Twin Oaks Convalescent Center | 24 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.