Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Azria Health Park Place during CMS and state inspections, most recent first.
A resident with TBI, cognitive impairment, and multiple chronic conditions was allowed to sign out AMA after a conflict over the smoking policy and was sent by cab to a homeless shelter without his meds. Staff did not involve the SSD before discharge, and the resident was later found confused, unable to explain where he came from or how he arrived, and unable to meet basic needs, leading to hospital admission on a court order.
Repeated Food Sanitation Deficiency Cited Across Multiple Surveys: F812 Food Procurement, Store/Prepare/Serve-Sanitary was cited again after being identified on the prior 2 recertification surveys and a recent complaint survey at a harm level. The facility’s QAPI plan described an ongoing, data-driven process for identifying deficiencies and monitoring corrective actions, and the Administrator acknowledged the repeated citation during interview.
Failure to Offer Recommended Flu and Pneumococcal Vaccines: The facility failed to offer indicated influenza and pneumococcal vaccines to 4 of 5 reviewed residents. The affected residents had significant medical histories, including chronic respiratory disease, heart disease, PVD, diabetes, and oxygen use. EHR entries showed vaccine administration with no documentation of offering, education, or declination before the recorded time, while progress notes showed the vaccines were actually given later. The IP stated she used the IRIS registry and an immunization tracker but had missed these residents.
Incorrect Pureed Diet Portions Served: Staff served residents on pureed diets the wrong portion sizes during lunch service. The cook used incorrect scoop sizes for pureed beef stew, vegetables, biscuit, and dessert, resulting in smaller servings for some items and a larger serving for the dessert than the recipe sheets required. The CDM acknowledged the residents did not receive the appropriate amount of food.
Improper food handling and kitchen sanitation were observed during meal service. A Dietary Aide placed hands on the rims of cups, carried room trays with dessert not fully covered, and worked in the kitchen without a beard net despite having a beard. A Cook repeatedly used the same gloved hand to handle lettuce and cheese, touched multiple surfaces and utensils between tasks, and the kitchenette and food cart were observed with food and fluid splatter. The CDM stated staff were expected to avoid hand contact with cup rims, fully cover room trays, change gloves between tasks, and wear beard restraints.
Failure to limit PRN psychotropic medication to 14 days. A resident with moderate cognitive impairment and diagnoses including anxiety disorder and depression had a PRN lorazepam order for anxiety and SOB that remained active beyond the 14-day limit, despite no administration on the MAR. Pharmacy MRRs twice noted CMS requires a 14-day stop unless the prescriber documents a rationale and new duration, but the record lacked a facility response, and the DON acknowledged the order exceeded the limit without rationale or an end date.
A resident with depression and psychotic disorder was not referred for a Level II PASRR after a physician documented increased delusions, hallucinations, and a new dx of delusional disorder with an antipsychotic order. The only PASRR in the record was outdated and did not reflect the resident’s later mental health dxs or psychotropic use, and the SS Director stated he had not been informed of the change.
A resident with significant weight loss did not have dietary interventions implemented in a timely manner. The RD documented repeated weight-loss triggers and recommended increasing a house supplement, while the DON said the recommendation was faxed to the provider and not acted on until she later called to update the order. The COO stated staff should have used other communication methods when the provider did not respond.
Dialysis assessments were not consistently completed for a resident with renal failure who received hemodialysis. The care plan listed dialysis attendance, but it did not direct staff to complete pre and post dialysis assessments. The TAR included orders for pre/post VS, weight, and evaluation on dialysis days, yet the EHR showed only 10 logged assessments over the review period. The DON could not find further information, and an RN stated he performed pre- and post-dialysis checks including breakfast intake, VS, and the dialysis site, with a form intended for these assessments.
A resident with moderate cognitive impairment and multiple chronic conditions was receiving Haloperidol for major depressive disorder. Pharmacy MRRs repeatedly recommended an AIMS assessment upon initiation and noted that no initial AIMS was found in the EHR, but the record lacked a facility response and only one AIMS was completed later. The DON acknowledged the AIMS should have been completed upon admission because the resident was on an antipsychotic.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to offer and document COVID-19 vaccination education, consent, or declination for multiple eligible residents reviewed for vaccines. Three residents were documented as not up to date on their COVID-19 vaccines, and the EHRs showed vaccines given or ordered without prior documentation that the vaccine had been offered or discussed. The IP stated she uses IRIS, admission questioning, and an immunization tracker, but acknowledged missing the residents.
PASRR screening was not fully completed for a resident with cerebral palsy, anxiety, and depression. Although a Level I PASRR was initially submitted, it was cancelled for missing documentation, and the SSD did not verify the status or resubmit until months later, resulting in a Level II approval with specialized services identified. The Administrator acknowledged the delay and that the screening should have been completed at admission.
The facility failed to maintain kitchen sanitation and pest control, resulting in extensive water damage, pest infestations, and unsanitary food storage and preparation areas. Staff reported daily sightings of mice, cockroaches, and flies, with years of accumulated grime and recurring flooding making cleaning difficult. Cleaning logs were missing or outdated, and multiple residents and staff experienced gastrointestinal symptoms, including diarrhea and vomiting, which some attributed to the food served. Food containers were found contaminated with mouse droppings and dead maggots, and expired food was served to residents.
Surveyors found the facility failed to provide a clean, comfortable, and homelike environment, with observations of mold, musty odors, soiled mattresses and linens, water damage, and pest activity. There were repeated shortages of appropriately sized briefs, gloves, wipes, and linens, leading staff to use makeshift solutions and leaving residents in soiled conditions. Staff and residents reported infrequent cleaning, persistent odors, and confusion over cleaning responsibilities, all contributing to an environment that did not meet required standards.
The facility did not provide enough nursing staff to meet residents' needs for toileting and timely call light response, resulting in multiple residents waiting extended periods for assistance, including one left on the toilet for half an hour and another in a soiled brief. Staff and resident interviews, as well as facility records, confirmed frequent delays and inadequate staffing, with reliance on agency and management staff to fill gaps. Call light response times often exceeded the expected 15 minutes, and ongoing concerns were documented in resident council meetings and grievance logs.
Facility leadership failed to ensure adequate supplies of incontinence products and linens, resulting in staff using makeshift solutions for resident care. Multiple staff and residents reported persistent shortages, unclean resident rooms, and a kitchen infested with mice, cockroaches, and flies. The kitchen and other facility areas suffered from structural disrepair, flooding, and foul odors, with management often unaware or unresponsive to ongoing issues reported by staff.
The facility was repeatedly cited for infection control and homelike environment deficiencies, with QAPI meeting minutes showing ongoing discussion of the same issues without documented follow-through or resolution. The DON could not explain the lack of follow-through, and the RDO confirmed that previous leadership did not implement the QAPI plan as required.
Staff failed to follow infection control protocols during resident transfers and incontinence care, including not changing gloves or sanitizing hands between tasks, using a mechanical lift sling from another resident's room without sanitizing it, and not utilizing Enhanced Barrier Precautions for a resident with an indwelling catheter. These actions were inconsistent with facility policy and standard precautions.
Staff failed to lock bed brakes while providing care to a resident with significant mobility impairments, resulting in the bed moving and the resident expressing fear of falling. Additionally, staff did not follow manufacturer instructions for mechanical lift use during transfers for two residents, including improper sling attachment and incorrect positioning of the lift's leg bar. Facility policies and competency checks were found lacking in guidance and oversight for safe transfer practices.
The facility failed to protect residents from abuse, as evidenced by incidents involving rough handling and threatening behavior by a CNA. Despite complaints, the CNA continued to work without immediate suspension or investigation. The facility's delayed response and inadequate implementation of abuse policies placed residents at risk.
The facility failed to maintain a homelike environment by allowing clutter in the hallways of both the North and South Halls, leading to safety hazards and resident conflicts. Equipment such as mechanical lifts, carts, and wheelchairs obstructed passage, causing residents in wheelchairs to argue and staff to intervene. A surveyor also tripped over an open mechanical lift leg. The facility lacked specific policies for equipment storage and wheelchair transport, contributing to the unsafe conditions.
The facility was found to have significant sanitation and food safety deficiencies. Staff were observed handling food without proper hygiene, such as not washing hands and using bare hands to serve food. The kitchen had unsanitary conditions, including unlabeled and undated food items, improper hair net usage, and broken equipment. A container of strawberries was found spoiled, indicating poor adherence to food storage policies. The dietician and DON confirmed the need for proper sanitation practices.
The facility failed to report abuse allegations involving three residents in a timely manner, leading to an Immediate Jeopardy situation. One resident reported rough treatment during pericare, while another was allegedly handled roughly and threatened by a CNA during a transfer. Delays in reporting these incidents to authorities violated facility policies and placed residents at risk.
The facility experienced significant delays in responding to resident call lights, with documented response times often exceeding 20 minutes and sometimes extending over an hour. Resident council meetings and interviews highlighted ongoing concerns about these delays, particularly during weekends and night shifts. Despite efforts to maintain adequate staffing and improve response times, the facility's policy expectation of answering call lights within 15 minutes was not consistently met.
The facility failed to provide required Medicare Liability Notices and Beneficiary Appeals forms to three residents within the mandated 48-hour window after the end of skilled services. Two residents did not receive the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), and one resident's SNFABN lacked the necessary cost disclosure.
A facility failed to accurately document a resident's discharge destination in the MDS assessment, indicating a hospital discharge instead of a community setting. The error was acknowledged by the Social Worker, who suggested it might have been due to the resident's initial hospital admission.
A facility failed to update the PASRR level 1 screening for a resident with moderate cognitive impairment and multiple diagnoses, including a delusional disorder. The resident's care plan and medication records indicated changes in treatment that required a new PASRR screening, which was not submitted. The oversight was acknowledged by the facility's social worker and regional nurse consultant.
The facility failed to track and document behaviors for residents on psychiatric medications, leading to discrepancies in records. A resident with moderate cognitive impairment and multiple diagnoses was on antipsychotic therapy, but the care plan lacked specific behavioral interventions. Another resident with similar impairments had inconsistent documentation of behaviors in the MAR and EHR. A third resident with intact cognition had discrepancies between nursing notes and the EHR. Staff interviews revealed a lack of awareness of behavior monitoring duties.
A resident with Diabetes Mellitus did not receive insulin correctly due to an LPN's failure to follow proper procedures. The LPN did not prime the insulin pen, hold it to the skin for the recommended time, or perform hand hygiene. Interviews with staff confirmed these steps were not followed, which could result in incomplete medication administration.
Unsafe AMA Discharge of Cognitively Impaired Resident
Penalty
Summary
The facility failed to safely discharge a resident with traumatic brain injury and moderate cognitive impairment when he was allowed to leave against medical advice after becoming upset about the smoking policy. The resident had a history of inability to care for himself, cognitive deficits, anxiety, depression, seizure disorder, cirrhosis, renal insufficiency, and functional dependence for multiple activities of daily living. His care plan identified impaired cognitive function and long-term discharge planning needs, and prior hospital records documented that he needed safe placement and was not capable of making healthcare decisions in his own best interest. On the day of discharge, nursing staff documented that the resident was smoking in his room, refused to surrender his lighter, and stated he would leave. An AMA form was signed, his belongings were gathered, and he left the facility by cab. The facility did not contact the social services director before the discharge, and the administrator stated he did not contact the corporate nurse or physician until after the resident had already left. The resident was discharged without his medications and without a documented safe discharge location that met his needs. After leaving the facility, the resident went to a homeless shelter where staff documented that he was very confused, could not reliably state where he came from, did not know how he arrived, and could not meet basic self-care needs. Shelter staff later reported he was unable to identify himself consistently, was incontinent, wandered, and required assistance with hygiene. He was then taken to a hospital and admitted on a court order. Hospital and psychiatric records described significant cognitive impairment, disorientation, poor short-term memory, limited insight, and inability to articulate a safe or realistic plan for food, shelter, or medications.
Repeated Food Sanitation Deficiency Cited Across Multiple Surveys
Penalty
Summary
F812 Food Procurement, Store/Prepare/Serve-Sanitary was cited at the current recertification survey after the facility failed to correct the same deficiency that had also been cited at the previous 2 recertification surveys and at a recent complaint survey at a harm level. The facility reported a census of 51 residents. The report states that the concern involved the facility’s food procurement, storage, preparation, and serving sanitation practices, and that this issue remained present across multiple surveys. The facility’s QAPI policy, dated 2001, states that the program is intended to be ongoing, facility-wide, and data-driven, with processes for tracking and measuring performance, setting goals and thresholds, identifying and prioritizing deficiencies, analyzing underlying causes, developing corrective actions, and monitoring the effectiveness of those actions. During an interview on 12/04/2025 at 1:15 PM, the Administrator acknowledged that F812 had been cited on the current survey, the previous 2 surveys, and a recent complaint survey.
Failure to Offer Recommended Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer the recommended pneumococcal and influenza vaccines to 4 of 5 residents reviewed for vaccination status. Resident #14 had diagnoses including chronic respiratory disease, heart disease, peripheral vascular disease, and diabetes, and the MDS documented oxygen therapy; the MDS also indicated the influenza vaccine was not given because it was not offered. Resident #33’s MDS indicated she was not up to date with pneumococcal vaccination because it was not offered. Resident #41’s MDS indicated he was not given the influenza vaccine and did not identify a reason. Resident #50’s MDS indicated she was not up to date with pneumococcal vaccination because it was not offered. For each of these residents, the EHR showed vaccination entries with a time of 12:00 AM and no documentation that the vaccine had been offered, education provided, or a declination recorded before that time. The progress notes showed the actual vaccination times were later than the EHR entries: Resident #14 received influenza vaccine at 7:15 PM on 12/3/25, Resident #33 received pneumococcal vaccine at 7:15 AM on 12/4/25, Resident #41 received influenza vaccine at 7:18 AM on 12/4/25, and Resident #50 received pneumococcal vaccine at 7:02 AM on 12/4/25. On 12/03/2025, a list of missing vaccinations for 4 residents was provided to the Infection Preventionist, who requested documentation of offering and refusal or vaccination given. During interview, the Infection Preventionist stated her process was to check the IRIS database, ask residents on admission, and offer yearly required vaccinations, using an immunization tracker. When asked how 4 of 5 reviewed residents were missing vaccinations, she stated she must have missed them and took responsibility. She also stated that after becoming aware of the missing vaccinations, she obtained orders and administered them. Facility policies stated residents were to be offered influenza vaccine annually and pneumococcal vaccine prior to or upon admission, with pneumococcal vaccination offered within 30 days of admission unless medically contraindicated or already vaccinated. CDC adult immunization guidance cited in the report addressed recommended pneumococcal and annual influenza vaccination for eligible adults.
Incorrect Pureed Diet Portions Served
Penalty
Summary
The facility failed to ensure residents on therapeutic pureed diets were served the correct amount and serving size. During observation, the cook prepared pureed lunch items using the recipe sheets, and the serving scoops were identified for each item. Staff reported that three residents were on a full pureed diet and one resident was on a pureed meat diet. Review of the EHR showed diet orders for Residents #24, #40, and #42 for a general diet with pureed texture, and Resident #38 for a general diet with mechanical soft texture, thin consistency, and pureed meats. During lunch service, the cook placed scoops into the pureed food items on the steam table and used a #16 scoop for the pureed beef stew, vegetables, and biscuit, and a #8 scoop for the pureed frosted chocolate cake. Review of the Sysco Dining Manager recipe sheets showed the pureed dessert should have been served with a #10 scoop, the vegetables with a #12 scoop, the beef stew with 2 servings of a #8 scoop, and the biscuit with a #12 scoop. The residents received smaller servings of the vegetables, beef stew, and biscuit than required, and a larger serving of the dessert. The CDM stated staff are expected to use the appropriate serving scoop size and acknowledged the residents did not receive the appropriate amount of food.
Improper Food Handling and Kitchen Sanitation
Penalty
Summary
Staff failed to use proper food handling and sanitation practices during meal service and food preparation. During lunch service, a Dietary Aide placed his hand directly on the rim of coffee cups while serving drinks to four residents, carried two room trays with dessert not covered, and later delivered additional room trays with dessert only partially covered by a plastic lid. The Certified Dietary Manager stated staff were expected not to place hands on the rim of cups or glasses and expected all food to be completely covered on room trays before leaving the dining room. During observations in the main kitchen and kitchenette, a Dietary Aide with a beard was seen preparing food without a beard net and later stacking and delivering plastic cups with his hand on the rim of the cups. The kitchenette area had splattered fluid and food on the swinging door, walls, door frame, and utility sink walls, and the insulated food cart used to transport food from the basement kitchen to the dining room also had food and fluid splattered on the outside. The CDM acknowledged that male staff with beards had not been wearing beard nets and stated the facility did not have beard nets available. During lunch preparation, a Cook handled food with a gloved hand but repeatedly placed that same hand into containers of lettuce and shredded cheese, touched plates, utensils, paper tickets, and surfaces between tasks, and continued plating without changing gloves. The Cook also used tongs only near the end of service after approximately 10 room trays remained. The facility policy stated bare hand contact with food is prohibited, gloves are to be changed between tasks, and food service staff are to wear hair restraints, including beard restraints, while the sanitation policy required kitchen and dining areas to be kept clean and sanitary.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to limit a PRN psychotropic medication to 14 days for Resident #21. The resident had a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses that included debility, cardiorespiratory conditions, renal insufficiency, diabetes mellitus, anxiety disorder, and depression. The resident had an order for lorazepam oral solution 0.5 mg every 12 hours as needed for anxiety and shortness of breath, with an order date of 8/29/25 and a discontinue date of 12/3/25. Review of the MAR for August through December showed the medication was not administered. The resident’s EHR contained pharmacist medication regimen reviews dated 10/14/25 and 11/13/25, both noting that CMS requires a 14-day stop on PRN psychotropic medications unless the prescriber documents a clinical rationale for continued use and a new duration, and both recommending discontinuation of the PRN lorazepam order due to non-use. The record lacked a facility response to either recommendation. During interview, the DON acknowledged the PRN lorazepam order exceeded 14 days without a rationale or end date and acknowledged the facility did not respond to the pharmacy recommendations. The facility policy stated PRN psychotropic medications are limited to 14 days unless the prescriber documents the rationale for extending use and includes the duration.
Failure to Update PASRR After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR evaluation after a new mental disorder diagnosis was documented. The resident’s quarterly MDS dated 9/17/25 listed depression and psychotic disorder, and the care plan included a resolved focus area for antipsychotic medications for behavior management. A physician encounter note dated 12/17/24 documented increased delusional behavior with hallucinations and ordered a new diagnosis of delusional disorder, along with an antipsychotic medication. Review of the resident’s electronic health record on 12/4/25 found only a PASRR dated 7/13/22, which did not include depression, delusional disorder, or psychotropic medication use. The Social Services Director stated he had not been informed of the resident’s new diagnosis or medications and acknowledged that no PASRR had been completed since admission. He also stated the facility had recently changed the process to include providing copies of visit notes and orders to him. The facility policy stated that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders, but it did not address updated screenings based on a resident change of condition.
Delayed Dietary Intervention for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to implement dietary interventions in a timely manner for a resident with significant weight loss. Resident #44’s record showed a height of 72 inches and a weight of 122 pounds, with the MDS documenting a loss of 5% or more in the last month and 10% or more in the last 6 months. The care plan identified inability to maintain nutrition and directed staff to provide supplements as ordered. The EHR showed the resident weighed 138.5 pounds on 5/5/25 and 122 pounds on 11/6/25, an 11.91% loss. The RD documented a significant weight loss trigger on 10/9/25 at a weight of 125 pounds and again on 11/25/25 at 122 pounds, recommending increasing the house supplement to 240 milliliters at 10:00 am while maintaining the 120 milliliters afternoon/evening supplement. The RD also stated the resident had long-standing thinness and other interventions had been used, including weighing him without his coat, bringing a breakfast sandwich outside when he smoked during breakfast hours, finger foods, and substitute meals. The COO stated the DON was responsible for following through on RD recommendations, while the DON stated the recommendation had been faxed to the provider and the provider never replied until she called that day and updated the order. The COO further stated staff should have used other communication methods, including calling or speaking to the provider in person, and noted the NP was in the building weekly.
Dialysis Assessments Not Consistently Completed
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for one resident who required hemodialysis. Resident #6 had diagnoses that included renal failure, scored 14 out of 15 on the brief interview for mental status, and the MDS documented he received hemodialysis during the last 14 days of the look-back period. The care plan included a focus area for dialysis and noted the resident attended dialysis on Monday, Wednesday, and Friday, but it did not direct staff to perform pre and post dialysis assessments. The TAR for November 2025 reflected an order dated 11/6/25 to complete pre/post vital signs and weight, as well as a pre/post evaluation, twice a day every Monday, Wednesday, and Friday. The EHR evaluation section showed pre and post dialysis assessments were logged a total of 10 times between 11/7/25 and 12/3/25. During interview, the DON stated she would look into the resident's pre and post dialysis assessments and later said she could not find any further information on the assessments. An RN stated he assessed what the resident ate for breakfast, vital signs, and the dialysis site before dialysis, and after return he offered food and reassessed vital signs and the dialysis site; he also stated there was a form for pre and post dialysis that was to be completed. The facility policy for End-Stage Renal Disease, Care of a Resident with, revision date September 2010, stated staff education and training includes the type of assessment data to be gathered about the resident's condition on a daily or per shift basis.
Failure to Complete Recommended AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to follow through on Pharmacy Medication Regimen Review recommendations for Resident #21, who had diagnoses including debility, cardiorespiratory conditions, renal insufficiency, diabetes mellitus, respiratory failure, anxiety disorder, and depression. The resident’s MDS assessment showed a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment, and the care plan identified antipsychotic use with a goal of remaining free of psychotropic drug-related complications, including movement disorder. The EHR showed the resident was receiving Haloperidol 5 mg tablets, 0.5 tablet by mouth twice daily, starting on admission for major depressive disorder. The resident’s EHR contained Pharmacy MRRs dated 9/28/25, 10/14/25, and 11/13/25, each stating that because the resident was taking Haloperidol, an AIMS assessment was recommended upon initiation, during dosage changes, and at least every 6 months, with the instruction to complete an AIMS assessment now. The 11/13/25 review also noted that an initial AIMS was not found in the EHR. The record lacked a facility response to these recommendations, and the EHR showed only one AIMS evaluation completed on 12/1/25. During interview, the DON acknowledged the AIMS assessment was not completed until December 1 and should have been completed upon admission because the resident was on an antipsychotic.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer the recommended COVID-19 vaccine to eligible residents for 3 of 5 residents reviewed for vaccines. Resident #14 was admitted on 10/16/25 and the MDS dated 10/22/25 documented that he was not up to date with his COVID-19 vaccination. The EHR showed he received the COVID-19 vaccine on 12/4/25 at 12:00 AM with no education documented, and the record lacked documentation of offering, education, or declination before that time. The progress notes indicated the vaccine was actually given at 8:14 AM on 12/4/25. Resident #41 was admitted on 6/16/1920 and the MDS dated 10/8/25 documented that he was not up to date with his COVID-19 vaccination. The EHR showed he received the COVID-19 vaccine on 12/4/25 at 12:00 AM with no education documented, and the record lacked documentation of offering, education, or declination before that time; progress notes indicated the vaccine was actually given at 8:20 AM on 12/4/25. Resident #50 was admitted on 11/20/25 and the MDS dated 11/23/25 documented that she was not up to date with her COVID-19 vaccination. The EHR showed consent and an order to give COVID-19 on 12/3/25 at 6:33 PM, but lacked documentation that the vaccine had been given before surveyors exited and also lacked documentation of offering, education, or declination before that time. On 12/03/2025, Staff A, Infection Preventionist, was given a list of missing vaccinations for 4 residents and stated she would look into it; during interview on 12/4/25, she stated her process was to look in IRIS, ask residents on admission, and offer yearly required vaccinations, and said she must have missed them.
PASRR Screening Not Completed Timely
Penalty
Summary
The facility failed to fully submit a Level I PASRR evaluation to the appropriate state-designated authority prior to admission or within 30 days for one resident. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and diagnoses included medically complex conditions, cerebral palsy, anxiety disorder, and depression. The resident’s original admission date was documented as 3/3/25, but the EHR lacked documentation of a Level I PASRR submitted prior to admission or within 30 days of admission. During interview, the Social Services Director stated he submitted a Level I PASRR the prior week and that it resulted in a Level II, time-limited approval. Review of the PASRR record showed a Level I screen had been submitted on 3/15/25 but was cancelled because the submitter did not provide requested documentation. A new Level I screen was not submitted again until 11/8/25, and the resulting Level II assessment identified services and supports. The Social Services Director acknowledged he did not realize the March submission had been cancelled and did not check the resident’s PASRR status or resubmit until November. The Administrator stated the PASRR screening should have been fully completed when the resident was admitted and acknowledged the gap from March to November 2025.
Widespread Kitchen Sanitation and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a safe and hygienic manner, resulting in unsanitary conditions and pest infestations. Direct observations revealed significant water damage in the kitchen and basement, including missing and collapsing ceiling tiles, moist surfaces, and water beading near food preparation areas. The kitchen floor was covered in sticky substances and food particles, with blackened grout in high-traffic areas. Multiple sticky traps containing rodent droppings, fur, and insects were found near dry storage, and peaches past their expiration date were served to residents. Small worm-like insects and insect eggs were observed in floor drains filled with food debris, and rodent droppings were found under and in front of the oven. Mold-like substances were present on sponges and in floor drains, and kitchen equipment was covered in grime. Unlabeled and open bags of food were found in freezer units. Staff interviews confirmed ongoing issues with rodents, cockroaches, ants, and flies in the kitchen, with several staff members reporting daily sightings of mice and expressing frustration over the lack of management response. Staff described the kitchen as extremely dirty and difficult to clean, with years of accumulated grime and recurring flooding during heavy rain. Cleaning logs were missing or incomplete, with the last documented logs dating back several months. The pest control contractor's records noted ongoing sanitation issues, such as standing water and accessible garbage, but did not document pest activity, which was inconsistent with staff and resident reports. The dietary manager and other staff confirmed frequent rodent activity, including the discovery of mouse nests and droppings in food storage areas. Residents and staff reported an increase in gastrointestinal symptoms, including diarrhea and vomiting, over the past month. Several residents and staff attributed these symptoms to the food served at the facility, with some residents reporting persistent diarrhea since admission. The infection preventionist did not track single-day episodes of gastrointestinal symptoms, but surveillance records documented multiple cases of diarrhea, vomiting, and abdominal pain, including one resident hospitalized with colitis. The kitchen and storage areas were found to have food containers contaminated with mouse droppings, dead maggots, and sticky residues, further indicating a failure to protect food from contamination and maintain sanitary conditions.
Failure to Maintain Clean, Homelike Environment and Adequate Resident Care Supplies
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions throughout the building. Surveyors noted the presence of black substances resembling mold and dirt in air conditioning vents, musty odors, missing wall bases, stained and soiled mattresses and linens, and evidence of water damage such as caved-in ceilings and water-stained walls. The North and South Halls, shower rooms, laundry, and basement areas all exhibited significant cleanliness and maintenance issues, including cracked tiles, biofilm in drains, missing non-skid strips, and the presence of mouse droppings and flies. Residents and staff reported persistent odors of urine and infrequent cleaning of rooms and equipment, with some residents lying in soiled beds and reporting that their rooms were not cleaned regularly. The facility also failed to maintain adequate supplies of personal care items and linens. Observations revealed repeated shortages of appropriately sized briefs, gloves, cleansing wipes, and linens in both the North and South Hall supply rooms, as well as the central supply area. Staff interviews confirmed that shortages were frequent, with staff sometimes resorting to makeshift solutions such as stapling briefs together or using washcloths in place of wipes. Staff reported that supplies often ran out before new shipments arrived, and that communication about supply needs did not always result in timely restocking. Residents corroborated these accounts, stating that they were sometimes left in soiled conditions due to lack of supplies, and that the facility often ran short on briefs and other essentials, especially toward the end of the week. Interviews with staff and residents further highlighted the impact of these deficiencies. Residents described being dressed in wet beds, smelling of urine, and seeing mice in their rooms. Staff reported confusion over responsibilities for cleaning mattresses and equipment, and housekeeping staff indicated that they did not clean mattresses or strip linens. The facility's policies required a clean, sanitary, and homelike environment, but observations and interviews demonstrated that these standards were not being met. The lack of adequate supplies and poor environmental maintenance directly contributed to the failure to honor residents' rights to a safe and comfortable living environment.
Failure to Provide Sufficient Staff for Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly in the areas of toileting assistance and timely response to call lights. Multiple observations documented residents waiting extended periods for assistance, including one resident with a history of hip fracture and impaired mobility who was left sitting on the toilet for half an hour with her catheter bag improperly positioned, and another resident who waited in a soiled brief for staff to assist with changing. Call lights were observed to be activated for prolonged periods without response, and residents and their roommates reported repeatedly calling for help without timely staff intervention. Interviews with residents revealed consistent concerns about delayed responses to call lights, with some reporting waits of up to two hours for assistance with transfers and personal care. Residents described staff placing multiple briefs on them to reduce the frequency of changes, which caused discomfort. Staff interviews confirmed that staffing levels were inadequate, with frequent reliance on agency staff and management personnel filling in for direct care roles. Staff reported being called to work extra hours and noted that most residents required assistance from two staff members, especially for transfers involving mechanical lifts. Review of facility records, including call light response reports, resident council meeting notes, and the facility assessment, corroborated the observations and interviews. Call light response times frequently exceeded the facility's 15-minute expectation, with some instances documented at over an hour. Resident council notes and grievance logs indicated ongoing concerns about call light response times, with multiple residents expressing dissatisfaction over several months. The facility assessment acknowledged the high acuity and dependency of the resident population, but staffing plans and actual staffing levels did not consistently ensure timely care and response to resident needs.
Failure to Maintain Adequate Supplies, Cleanliness, and Pest Control
Penalty
Summary
Facility leadership failed to provide adequate management, resulting in insufficient incontinent and linen supplies, unclean resident environments, and a kitchen infested with vermin. Observations revealed black substances on air conditioner vents, missing wall bases, stained and unmade beds, foul odors, and minimal supplies in utility rooms. Staff interviews confirmed frequent shortages of gloves, wipes, and briefs, with staff resorting to makeshift solutions such as using washcloths or tying pull-ups to fit residents. Residents and staff reported running out of clean linens regularly, and soiled linens with deep stains were observed, some of which could not be cleaned and had to be discarded. Multiple staff and residents reported ongoing pest infestations, including mice, ants, cockroaches, and flies, particularly in the kitchen and resident rooms. The kitchen was described as extremely dirty, with years of accumulated grime, frequent flooding, and evidence of rodent nests and droppings. Staff reported that management was repeatedly informed of these issues, but little to no action was taken. The kitchen also suffered from structural issues such as leaking ceilings and standing water, and cleaning documentation was lacking or unavailable. Housekeeping and maintenance concerns extended to other facility areas, with reports of leaking ceilings, water-stained walls, and mice droppings found on laundry. Staff and residents noted that rooms were not cleaned frequently enough, and pest issues were downplayed by management. Leadership, including the Acting Administrator and Regional Director of Operations, were often unaware of the extent of the problems, citing lack of staff reporting and infrequent presence in affected areas. The facility's failure to maintain a clean, safe, and adequately supplied environment was corroborated by resident council meeting notes and multiple staff and resident interviews.
Failure to Address Repeated Quality Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective process for addressing previously identified quality deficiencies, as evidenced by repeated citations for infection control and maintaining a safe, clean, and homelike environment in both 2023 and 2024. Despite the facility's QAPI plan outlining a monitoring process using multiple data sources, it did not specify a method for addressing recurring deficiencies. Review of QAPI meeting minutes since November 2024 revealed that the same issues were repeatedly discussed without documented follow-through or resolution. During interviews, the DON, who serves as the acting QAPI designee, was unable to explain the lack of follow-through or documentation regarding these repeated issues, and the RDO acknowledged that previous leadership had not implemented the QAPI plan as intended.
Failure to Follow Infection Control Practices During Resident Care and Transfers
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during direct observation, record review, and staff interviews. Staff were observed transferring a resident with an indwelling catheter using a mechanical lift sling taken from another resident's room without sanitizing it, and without utilizing Enhanced Barrier Precautions (EBP) as required for residents with indwelling medical devices. Staff interviews confirmed that EBP should have been used during such high-contact activities, and that each resident should have their own clean sling or a properly sanitized one if shared. In another instance, staff provided incontinence care to a resident with chronic conditions including a left above-knee amputation and moisture-associated skin disorder. During care, staff failed to consistently change gloves and sanitize hands between tasks, and handled clean supplies and equipment with contaminated gloves. Soiled linens were placed on top of a trashcan in the resident's room, and the mechanical lift was wheeled to a common area after use, raising concerns about environmental contamination. Additionally, staff were observed providing pericare to a resident with dementia and incontinence without changing gloves or sanitizing hands between dirty and clean tasks. Interviews with the Infection Preventionist, Director of Nursing, and other nursing staff confirmed that facility policy requires glove changes and hand hygiene between tasks and after glove removal, as well as disinfection of equipment between residents. These lapses were inconsistent with the facility's own infection control policies and standard precautions.
Failure to Lock Bed Brakes and Improper Mechanical Lift Use During Resident Transfers
Penalty
Summary
Staff failed to lock the brakes on a resident's bed while providing incontinence care and repositioning, resulting in the bed moving during the process. The resident, who had a history of left above-the-knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder, was dependent on staff for transfers and had a documented risk for falls. During the observed care, the resident expressed concern about falling, and the Regional Nurse present confirmed that the bed brakes were not engaged and that the resident was positioned close to the edge of the bed. Additionally, staff did not operate a mechanical lift according to manufacturer instructions during transfers for two residents. In one instance, the sling strap was looped around the armrest of a wheelchair, requiring adjustment while the resident was suspended in the lift. The mechanical lift's leg bar was not spread as recommended by the manufacturer during the transfer, and the lift encountered obstacles under the bed. The staff involved did not demonstrate competency in the safe use of the mechanical lift, and the facility's policy lacked specific guidance on the correct positioning of the lift's leg bar during transfers. Interviews with facility leadership confirmed that staff were expected to follow manufacturer instructions for mechanical lifts, but there had been no recent competency audits or survey preparation related to transfers. The facility's observation form for lift/transfer safety did not include detailed steps for using mechanical lifts, and the relevant policies did not address the specific issues observed during the transfers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving three residents. One resident reported experiencing pain after pericare was performed by a CNA, who was described as rough. Despite the resident's complaint, the CNA continued to work without immediate suspension or investigation. The resident's care plan noted a history of false allegations, but the facility did not take immediate action to ensure the resident's safety or investigate the claim thoroughly. Another incident involved a CNA reportedly using excessive force while repositioning a resident and making threatening statements. The CNA continued to work with residents until the incident was reported to the DON two days later. The resident involved had communication deficits, making it difficult to ascertain the full extent of the incident. The facility's delayed response and failure to immediately suspend the CNA placed residents at risk. The facility's investigation into these incidents was inadequate, as staff continued to work without proper oversight or immediate action. The facility's policies on abuse and neglect were not effectively implemented, leading to a situation where residents were not adequately protected from potential harm. The lack of timely reporting and investigation of abuse allegations contributed to the deficiency.
Removal Plan
- All facility staff education provided on Abuse and Neglect Standards and Reporting.
- The facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
Cluttered Hallways and Lack of Policies Lead to Unsafe Environment
Penalty
Summary
The facility failed to ensure a homelike environment and reduce clutter in the hallways of both the North and South Halls, which led to several incidents involving residents and staff. Observations revealed that equipment such as mechanical lifts, shower chairs, PPE bins, trash and soiled laundry carts, medication carts, treatment carts, and wheelchairs were parked along the hallways and handrails, obstructing passage. On multiple occasions, residents in wheelchairs were unable to pass each other due to the clutter, resulting in arguments and the need for staff intervention. Additionally, a surveyor tripped over an open mechanical lift leg in the South Hall, further highlighting the safety hazards posed by the cluttered environment. The facility lacked specific policies for equipment storage and transporting residents in wheelchairs, as confirmed by interviews with the Regional Corporate Nurse Consultant and the Regional Director of Operations. The Homelike Environment policy, revised in February 2021, stated that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this case. The absence of a policy for equipment storage and the improper use of wheelchairs without foot pedals contributed to the unsafe and cluttered conditions observed in the facility.
Sanitation and Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and service, as observed during a survey. Staff C was seen serving dinner without washing her hands after licking her finger and touching her lips. Additionally, Staff D and Staff E were observed with improper hair net usage, allowing hair to hang outside the net. The kitchen inspection revealed several unsanitary conditions, including dried leaves and dirt on the floor, stained ceiling tiles, and unlabeled and undated food items in refrigerators and freezers. The facility's policies on food storage, preparation, and hygiene were not adhered to, as evidenced by the lack of proper labeling, dating, and storage of food items. Further observations showed that the dietary staff did not follow proper hygiene practices. Staff X and Staff T, both CNAs, were seen serving meals with their thumbs inside pudding bowls, and Staff X and Staff L handled dinner rolls with bare hands, applying butter and jelly without gloves. The facility's policies require gloves to be worn when handling ready-to-eat food and for gloves to be changed between tasks, which was not followed. The dietician and DON confirmed that staff should not have direct contact with residents' food without proper sanitation measures. The facility's equipment and storage areas were also found to be in poor condition. A refrigerator thermometer was broken, and the temperature was above the safe level for food storage. Unlabeled and undated food items, such as diced chicken and barbeque sauce, were found in the refrigerators and freezers. A container of strawberries in syrup was found to be spoiled, with visible mold and a foul smell, indicating it had been stored far beyond the recommended time. These findings highlight a significant lapse in maintaining food safety and hygiene standards as per the facility's policies.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations involving three residents, leading to an Immediate Jeopardy situation. For one resident, an incident occurred where the resident reported feeling pain during pericare, alleging rough treatment by a CNA. Despite the resident's initial complaint, the nurse's assessment found no physical signs of abuse, and the resident later denied any pain. However, the incident was not reported to the Department of Inspections, Appeals, and Licensing (DIAL) until several weeks later, indicating a delay in the reporting process. Another incident involved a resident with cognitive impairments who was allegedly handled roughly by a CNA during a transfer. The CNA reportedly made threatening remarks to the resident, which were overheard by another staff member. This staff member did not report the incident immediately, leading to a delay in addressing the potential abuse. The resident later confirmed feeling rough handling but denied feeling unsafe. The delay in reporting this incident to the appropriate authorities further contributed to the Immediate Jeopardy finding. The facility's policies required immediate reporting of abuse allegations, but staff failed to adhere to these protocols. The incidents were not reported within the required timeframes, and staff involved continued to work with residents, potentially placing them at risk. The facility's failure to protect residents from abuse and ensure timely reporting of allegations resulted in a serious deficiency, necessitating immediate corrective actions.
Removal Plan
- All facility staff education on Abuse and Neglect Standards and Reporting initiated. Facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
- Progress notes, grievances, and critical events reviewed routinely by facility staff to identify potential abuse, neglect, and exploitation opportunities, and act upon these immediately. The facility implemented an event tracking log to review these items routinely, and allow key staff to view approaching timelines, and trend and track the events.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, as evidenced by multiple instances of extended response times documented in resident council minutes, staff disciplinary records, and resident interviews. The resident council meetings consistently highlighted concerns about call light response times, with residents noting improvements but still expressing dissatisfaction. Staff disciplinary records for CNAs revealed repeated instances of call lights being left unanswered for over 20 minutes, with some response times extending to over an hour. Resident interviews corroborated these findings, with several residents reporting delays in receiving assistance, particularly during weekends and night shifts. The facility's policy on call light response, revised in September 2022, emphasized the importance of timely responses, yet the facility's staffing levels appeared insufficient to meet this standard consistently. The facility assessment indicated an effort to maintain adequate staffing, but the documented response times suggest that these efforts were not always successful. The Regional Director of Operations acknowledged the issue, noting that call light response times were part of the facility's Quality Assurance Performance Improvement process. Despite some improvements in response times since March 2024, the facility continued to experience significant delays, particularly during evening and night shifts. The Director of Nursing stated that the expectation was for call lights to be answered within 15 minutes, but this standard was not consistently met, as evidenced by the documented response times and resident feedback.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Medicare Liability Notices and Beneficiary Appeals forms to three sampled residents within the mandated 48-hour window after the end of skilled services. For Resident #26, the Notice of Medicare Non-Coverage (NOMNC) was issued and signed within the required timeframe, but the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was missing. Similarly, for Resident #204, the NOMNC was signed by the power of attorney within the required window, but the SNFABN was not provided. Resident #205 received both the NOMNC and SNFABN within the required timeframe, but the SNFABN lacked the necessary disclosure of the cost of services if the resident chose to pay out of pocket. Interviews with the Regional Director of Operations and the President of Clinical Reimbursement revealed uncertainty as to why SNFABNs were not issued for Residents #26 and #204. The President of Clinical Reimbursement confirmed that Resident #205's SNFABN should have included the cost of services. The facility's policy states that SNFABNs are to be provided if the beneficiary intends to continue services and the Skilled Nursing Facility believes the services may not be covered under Medicare.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment tool for one resident, leading to a discrepancy in the documentation of the resident's discharge destination. The MDS assessment for the resident indicated that he was discharged to a short-term general hospital, while other documentation, including the Discharge Plan and Notice of Transfer Form, indicated that the resident was discharged to a waiver-based housing with home health. This inconsistency was identified during a review of the resident's records. Interviews with facility staff revealed that the President of Clinical Services, who signs off on MDS assessments, was unaware of the reason for the incorrect documentation and speculated that the Social Worker might have selected the wrong option. The Social Worker acknowledged the error, stating that the resident was not discharged to the hospital and suggested that the mistake might have occurred because the resident was initially admitted from a hospital. The Social Worker admitted that the discharge to a community setting should have been documented on the MDS.
Failure to Update PASRR Screening for Resident with Significant Change
Penalty
Summary
The facility failed to submit a new preadmission screening and resident review (PASRR) level 1 screening for a resident who experienced a significant change in condition. The resident, identified as having moderate cognitive impairment, had a history of stroke, non-Alzheimer's dementia, hemiparesis, seizure disorder, depression, and psychotic disorder. The resident's care plan, revised in November 2024, documented a delusional disorder and the use of antipsychotic and antidepressant therapy. The medication administration record for November 2024 showed daily use of Olanzapine and Venlafaxine. The original PASRR level 1 screening from August 2022 did not document the resident's delusional or psychotic disorder, nor did it document depression or a seizure disorder, despite the resident's current treatment with Olanzapine. The facility's policy required a new PASRR screening if there was a significant change in treatment needs. The regional nurse consultant confirmed that the facility did not have an updated PASRR, and the social worker acknowledged that the change in treatment and diagnosis required a resubmission, which was overlooked during the resident's reevaluation.
Inadequate Behavioral Documentation for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately track and document behaviors for residents taking psychiatric medications, as evidenced by discrepancies in the records of three residents. Resident #32, with moderate cognitive impairment and multiple diagnoses including stroke and psychotic disorder, was on antipsychotic and antidepressant therapy. The care plan directed staff to use non-drug approaches but did not specify the behaviors or interventions. The Medication Administration Record (MAR) and nursing progress notes documented behaviors on various dates, yet the electronic health record (EHR) showed no behaviors, indicating a lack of consistent documentation. Resident #11, also with moderate cognitive impairment and psychiatric diagnoses, was receiving psychotropic medication. The care plan mentioned non-drug approaches but lacked specifics. The MAR included medications for psychiatric conditions but did not document non-pharmacological interventions for behavioral issues. Nursing progress notes and the EHR lacked consistent documentation of behaviors, with only one entry in the EHR noting no behaviors observed. Resident #24, with intact cognition and psychiatric diagnoses, was on psychotropic medication therapy. The care plan noted manipulative behavior but did not specify non-drug interventions. The MAR documented anxious behaviors on one day, while nursing progress notes recorded behaviors on multiple days, with specific behaviors noted only once. The EHR contained no documentation of behaviors, showing a discrepancy with the nursing progress notes. Interviews with staff revealed a lack of awareness and understanding of behavior monitoring responsibilities, contributing to the deficiency.
Failure to Administer Insulin Correctly
Penalty
Summary
The facility failed to administer insulin correctly to a resident with Diabetes Mellitus, leading to a significant medication error. During a medication pass, an LPN was observed administering insulin Lispro using a pen-injector without performing necessary steps such as priming the pen and purging two units of insulin to ensure it was functioning properly. The LPN also did not hold the pen to the resident's skin for the recommended duration to ensure complete administration of the medication. Additionally, the LPN did not perform hand hygiene before preparing the medication, which is a critical step in preventing contamination and ensuring patient safety. Interviews with the Regional Corporate Nurse Consultant and the Director of Nursing revealed that the LPN did not follow the manufacturer's instructions for the insulin pen, which included priming the pen and holding it to the skin for at least five seconds. The Director of Nursing stated that the expectation is for staff to follow these guidelines, and the Licensed Pharmacist confirmed that failure to perform these steps could result in the resident not receiving the full dose of medication. The manufacturer's insert for the Lispro pen injector also outlined these steps as necessary for safe and effective usage.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 405 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Center At Luther Park | 0.8 mi | ★★★★★ | 17 | 1 |
| Rehabilitation Center Of Des Moines | 0.9 mi | ★★★★★ | 14 | 0 |
| University Park Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Valley View Village | 2.1 mi | ★★★★★ | 4 | 0 |
| Ramsey Village | 2.4 mi | ★★★★★ | 44 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.