Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Bluff Nursing Home during CMS and state inspections, most recent first.
Failure to monitor significant weight loss and implement nutritional supplements for two residents. One resident with dementia and DM had repeated significant wt loss, was noted to be at risk for malnutrition, and had no further wt monitoring after a shake order was placed. Another resident with Alzheimer’s, CHF, CKD, and protein-calorie malnutrition had severe wt loss, poor intake, and was observed eating without the ordered nutritional shake; the dietitian stated both mighty shakes and 2 cal should have been provided, but the MAR showed the shake had been discontinued.
Kitchen Food Storage and Preparation Contamination: Surveyors observed unlabeled and undated frozen chicken-like products in the freezer, clean dish bins being handled on wet floor mats and then placed back with clean items, and hot water used for food prep with condensation dripping from the exhaust hood back into the kettle. The Dietary Supervisor acknowledged that frozen foods should be labeled and dated, the bins should not be placed on the floor, and dripping water back into the kettle can contaminate the cooking water.
Pureed diet food was not served in a smooth consistency for 4 residents on puree diets. During meal prep, an Asst Dietary Supervisor pureed pizza burgers with sauce, thickener, and water, but the mixture was not smooth and contained small bits of meat that had to be chewed. A resident on a pureed diet took one bite, chewed before swallowing, and stopped eating the item. Later, surveyors and the Dietary Supervisor confirmed the puree was not smooth and needed to be pureed longer.
A resident who said she had previously rolled out of bed and feared falling out again requested a wider bed on admission, but the request was not met. Nursing notes documented that she was anxious about her bed, found it uncomfortable, asked several times for another bed, and wished she had full side rails, while staff stated all available beds were the same model.
PRN psychotropic meds lacked required stop dates for three residents. One resident had a PRN antipsychotic order for agitation that was given multiple times without a stop date, and two residents had PRN lorazepam orders for anxiety/agitation without stop dates. The pharmacist flagged each order as needing compliance with the 14-day limit for PRN psychotropic meds unless the prescriber documented an extension.
An LPN delayed escalation for a resident who became lethargic, congested, diaphoretic, hypotensive, and hypoxic, and the resident was not sent to the ER until hours later; the resident was later hospitalized with hypoxia, AMS, sepsis, and elevated troponin. The facility also failed to apply ordered elastic wraps to two residents’ lower legs as directed, despite resident complaints and visible edema.
The facility failed to properly assess, treat, and care plan for two residents with pressure injuries. One resident with hemiplegia, aphasia, dysphagia, and other diagnoses had a newly acquired right ankle pressure injury that was not measured, not floated or elevated during care, not added to the care plan, and not listed on the pressure list. Another resident with a stage 3 left elbow pressure ulcer was observed without the ordered dressing or elbow pads in place, despite physician orders for daily dressing changes and offloading.
Improper Positioning of Indwelling Catheter Drainage Bag: A resident with an indwelling urinary catheter and diagnoses including bladder dysfunction, CKD, and a history of UTIs had a drainage bag observed secured to the lower thigh and not positioned below the bladder level. A CNA emptied the bag but did not secure the cap, and urine was seen dripping down the resident’s leg. A CNA stated that leg bags are for ambulatory residents and that drainage bags should be placed below the bladder to allow drainage and help prevent infections.
Staff failed to appropriately respond to dementia-related behaviors for multiple residents. A resident on a locked memory care unit repeatedly exit-seeked and became aggressive when prevented from going outside, while staff relied on redirection and PRN meds after escalation. Another resident was loudly scolded in the dining room after taking silverware, and a third resident was moved to a med room after wandering into female rooms and undressing, with staff reportedly telling him not to hit them and escalating his behavior. Care plans and notes did not show consistent individualized behavioral management.
Medication administration errors were identified during an observed med pass when an LPN failed to follow the ordered regimen for two residents. One resident received a PRN antipsychotic from a home med bottle containing mixed pills, and the LPN used a phone search to confirm the tablet before giving it. Another resident received several scheduled noon meds, but the LPN did not apply ordered Voltaren gel to both knees during the observed pass.
Medication Labeling and Expiration Deficiencies: An LPN was observed using a resident’s home meds even though the bottles contained mixed pills and did not match the MAR orders. In addition, two insulin pens were being used without proper open dates, and one was already beyond the 28-day use period; facility inspection reports also noted meds being used past expiration and not labeled with open dates.
Failure to Follow EBP, PPE, and Hand Hygiene Practices: A CNA brought a meal tray cart into a resident’s room while the resident was on EBP for Klebsiella pneumoniae in the urine, touched the resident’s bedding and bed controls without PPE, placed a towel from the floor onto the cart, and then delivered another resident’s meal tray from the same cart without hand hygiene or cart sanitization. The CNA said the cart should have stayed outside the room, and the unit coordinator stated that gloves and hand hygiene were required with isolation precautions.
Failure to Offer Maintenance Ambulation Assistance: A resident with limited mobility and a goal to maintain walking ability was not offered his daily maintenance ambulation plan. Staff assumed he would ask to be walked, even though he did not use his call light and would not ask for assistance. Documentation showed the ambulation task as completed, but the restorative nurse said that was incorrect and the resident did not walk that day.
A resident’s quetiapine was used for another resident when her own supply had not yet arrived from the pharmacy. An RN removed a card from the return bin and directed staff to use it for the other resident, even though staff stated this was not allowed and the medication should have come from stock cubex until the resident’s own card arrived. The DON confirmed medication cards are only to be used for the resident they are prescribed for, and the facility policy required the 6 rights of med admin.
A resident with lower extremity weakness and recurring wounds, who was on a restorative ambulation program to walk 50 feet with a wheeled walker and standby assist twice daily, did not consistently receive the ordered walking sessions after the restorative aide who had been walking with him left employment. The resident reported missed and reduced walks and filed a grievance that his walking rehab schedule was not being followed. Nursing and restorative staff stated that floor CNAs were responsible for providing the twice-daily walks without set times, but CNAs assigned to the resident over a weekend did not walk him and were unsure who was responsible for restorative ambulation. Review of the medical record showed no documentation of walk refusals for the dates the resident reported not being walked, despite care plan instructions to document refusals and notify the nurse.
A cognitively impaired, obese resident with impaired balance was transferred from bed to wheelchair using a sit-to-stand mechanical lift by two CNAs. After the resident was seated, one CNA left the room while the resident was still attached to the lift by a back strap. As the remaining CNA unhooked the strap, no one was holding the resident or stabilizing the wheelchair, and the resident leaned back, causing the wheelchair to flip backwards and the resident to fall onto the floor. This occurred despite facility policy and leadership expectations that two CNAs remain present and that one staff member stabilize the resident and wheelchair until fully disconnected from the lift. The resident later required hospital evaluation, where imaging showed an acute, unstable thoracic vertebral fracture related to the fall.
A cognitively impaired resident fell backwards from a wheelchair onto his back and was started on Tramadol for pain after a NP was notified by phone. Over the next two days, the resident’s back pain worsened, with documented yelling during movement, staying in bed, and refusing cares due to pain, yet nursing staff did not notify a physician or NP or obtain an in‑person assessment. The resident continued to experience severe pain and refusal of care until a NP and the resident’s POA were finally contacted, leading to transfer to the hospital, where imaging showed an acute, unstable thoracic vertebral fracture. The facility’s pain management policy requiring reassessment and revision of the pain regimen when pain is not adequately controlled was not followed.
A resident fell backwards from a wheelchair, developed lower back pain, and had a lumbar X-ray ordered by an NP. When the X-ray tech attempted the study, it could not be completed due to weight concerns, and the tech did not return with additional support as stated. Staff did not notify the physician, NPs, or the resident’s POA that the ordered X-ray was not completed, and there was no documentation of such notification. The resident’s back pain worsened and the resident was later sent to a hospital, where a thoracic vertebral fracture was diagnosed, revealing that the ordered lumbar X-ray had never been performed despite facility policy requiring appropriate diagnostic services.
A resident with severe cognitive impairment and total dependence for ADLs was found in bed with saturated linens, incontinence brief, and mattress due to delayed incontinence care. Staff were unaware of the last time the resident was checked or changed, and the resident expressed discomfort. The care plan and facility policy required frequent checks and changes, but these were not followed, resulting in the resident being left in a soiled state.
A resident with significant medical needs and a stage III pressure ulcer did not have the required physician-ordered dressing in place during a survey observation, despite documentation indicating the treatment was completed. Staff confirmed the absence of the dressing, representing a failure to follow wound care orders and facility policy.
Multiple residents at risk for falls did not have required safety interventions in place, including a bed alarm that was not properly positioned and call lights that were not within reach. These lapses occurred despite care plans and facility policies mandating such interventions, and resulted in at least one unwitnessed fall and residents being unable to call for assistance.
A resident with an indwelling urinary catheter was found with the catheter bag positioned above bladder level during wound care, causing urine to flow back toward the resident. Staff failed to reposition the bag and tubing below the bladder as required by the care plan and facility policy, resulting in a deficiency.
A resident with significant medical needs received medications and feeding through a gastric tube without proper verification of tube placement using an approved method. Nursing staff relied on outdated practices and were unable to locate a clear facility policy, while the DON acknowledged the policy was vague and under revision.
Two residents did not receive medications as ordered: one was left with medications at bedside without a documented self-administration assessment or care plan, and another did not receive a scheduled dose of lisinopril due to a change in administration time and lack of MAR verification by nursing staff.
Staff did not wear gowns, as required by enhanced barrier precautions, while providing incontinent care and performing a dressing change for a resident with a stage III pressure ulcer. Although gloves were used, the omission of gowns occurred despite clear signage, care plan instructions, and facility policy mandating both gloves and gowns for high-contact care activities.
A resident with Alzheimer's and severe dementia was involved in an abuse incident when a housekeeper attempted to restrain him by grabbing his wrists and walking him backwards, causing the resident to fall. Staff members confirmed that the appropriate response should have been to walk away and allow the resident to calm down. The facility's policy defines such actions as abuse, leading to the housekeeper's termination.
The facility failed to report and investigate an incident where a resident hit another resident, despite multiple staff witnessing the event. Statements were taken by a former ADON, but no formal investigation or report was completed. The administrator and current DON were unaware of the incident, indicating a failure in communication and adherence to the facility's abuse policy.
A resident with multiple health conditions filed grievances but only received verbal responses, contrary to the facility's policy requiring written decisions. The resident requested written responses, particularly for a grievance involving disrespectful staff interaction, but was informed that written resolutions were not provided.
A resident with severe cognitive impairment and a history of falls fell and fractured her hip due to the absence of a required chair alarm in her wheelchair. The chair alarm, intended to alert staff when the resident attempted to get up, was left in a recliner, leading to a delayed response from staff. The resident's care plan included the use of a chair alarm due to her risk factors, but it was not in place at the time of the incident.
A resident with a history of dementia and a left femur fracture experienced a fall and complained of hip pain. An X-ray was ordered but conducted nearly 36 hours later, revealing fractures. Staff indicated delays with the contracted X-ray company, and the resident's family was not informed of the delay or given the option for immediate evaluation. The facility's policy allowed for up to 24-hour delays, but this was not communicated to the family.
Failure to Monitor Significant Weight Loss and Implement Ordered Nutritional Supplements
Penalty
Summary
The facility failed to assess and monitor a resident after significant weight loss and failed to ensure nutritional supplements were implemented after significant weight loss, resulting in continued weight loss for two residents. R77 had diagnoses including dementia, Alzheimer’s disease, and type 2 diabetes. R77’s weights showed a drop from 207.6 lbs on 4/7/26 to 189 lbs on 5/1/26, which was an 8.7% loss in 24 days, and then further decline to 157 lbs on 6/17/26, an additional 16.49% decrease in 23 days. The record showed a nutritional assessment noting moderate decrease in food intake and no weight loss in the last 3 months, even though the weight record reflected a net loss during that period. R77 was identified as having a weight loss greater than 5% in the last month and was not on a physician-prescribed weight-loss regimen. A mini nutrition progress note dated 5/16/26 identified R77 as at risk for malnutrition. Staff and family reported that R77 had been eating poorly off and on since being placed on a pureed diet and did not like the pureed food. The nurse practitioner stated they had not been notified of weight loss until contacted by the RN, and the dietitian stated she was informed of the decrease in weight later and that R77 had not been reviewed for significant weight loss during the weekly weight meetings. After a shake supplement order was placed, the record showed no additional monitoring of R77’s weight, and the resident continued to lose weight. R67 had diagnoses including Alzheimer’s disease, CHF, dementia, CKD stage 3, protein-calorie malnutrition, and heart disease. Her nutrition note showed 20% weight loss in 6 months, severely underweight BMI, and variable intake of 25%-50%; it also recommended continuing mighty shakes and starting 2 cal 60 ml three times daily. During observation, R67 appeared thin with sunken eyes, sunken cheekbones, and bony upper extremities while eating breakfast, and she was not served her nutritional shake. The dietitian stated R67 triggered for significant weight loss and should have been receiving both mighty shakes and 2 cal, but the physician order sheets only included 2 cal and the MAR showed mighty shakes were discontinued.
Kitchen Food Storage and Preparation Contamination
Penalty
Summary
The facility failed to ensure clean kitchen pans and boiling water used for cooking were maintained in a manner to prevent contamination, and failed to ensure frozen food items were labeled and dated. During an initial tour of the kitchen with the Dietary Supervisor, the freezer contained multiple plastic bags of chicken-like products with no label identifying the contents and no date showing how old the product was. When asked how the contents were known, the Dietary Supervisor stated the cooks knew what was in the bags. During the same kitchen observation, the Dishwasher removed brown plastic bins from the clean side of the dishwashing machine and stacked them on wet floor mats next to the dishwasher, then placed them inside another clean plastic bin on the shelf under the clean side of the dishwasher. A brown plastic bin was also observed on the clean side of the dishwasher holding lids to resident cups. In addition, the Assistant Dietary Supervisor was pureeing foods at a prep counter and used a pitcher to obtain hot water from a large kettle-type pot to add to the pureed foods. Two kettle pots were located under an exhaust hood, and water drops had collected on the hood directly above the steaming boiling water kettle and were observed dripping back into the hot water used for cooking. The Dietary Supervisor stated frozen foods should be labeled with the contents and date opened, the brown bins should not be placed on the ground to prevent contamination, and the dripping water back into the kettle can contaminate the water used for cooking.
Pureed Diet Food Not Served Smoothly
Penalty
Summary
The facility failed to ensure pureed food was served in a smooth consistency for 4 of 4 residents reviewed for pureed diets (R70, R77, R110, and R125). During observation of noon meal preparation, the Assistant Dietary Supervisor pureed pizza burgers with tomato sauce, thickener, and water, then ran the mixture for only a few minutes and poured it into a serving pan without tasting it. The puree did not visibly appear smooth, and a surveyor tasted small bits of meat that had to be chewed. The pan was covered and placed in the warmer for lunch. At the noon meal, R110 took one bite of the pureed pizza burger and chewed before swallowing, then did not take another bite. Later, two surveyors again tasted the pureed pizza burger and found it was not smooth and contained bits of meat that needed to be chewed. The Dietary Supervisor then tasted it and stated it was not smooth and needed to be pureed longer. The facility’s roster showed that R70, R77, R110, and R125 were on a pureed diet, and the facility policy defined puree as food ground, pressed, and/or strained to a soft, smooth, thick paste similar to thick pudding.
Failure to Provide Requested Wider Bed
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing a wider bed after the resident requested one on admission. The resident stated she had fallen out of bed at the hospital and was afraid of falling out of bed again. Progress notes documented that she was anxious because of her bed, said the bed was not comfortable, was transferred to a recliner that was also not comfortable, and then returned to bed with the bed lowered all the way to the floor. The notes also state that the resident reported previously rolling out of bed, used hand holds on either side of the bed to reposition, wished she had full side rails, and asked several times if another bed was available. The nurse documented that all available beds were the same model at present. The resident later told the surveyor that she had asked for a wider bed on admission and had not received one.
PRN Psychotropic Medications Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure PRN psychotropic medications had stop dates for 3 of 6 residents reviewed for unnecessary medications in a sample of 36. R113’s June MAR showed quetiapine fumarate 50 mg PO every 24 hours PRN for agitation at HS with a start date of 6/5/26 and no stop date; the medication had been administered 6 times since it was ordered. The pharmacist’s recommendation noted that PRN psychotropic drugs are limited to 14 days unless the prescriber documents a rationale and duration for extension, and asked whether the order could be discontinued 14 days after the start date to maintain regulatory compliance. R12’s June MAR showed lorazepam intensol oral concentrate 2 mg/ml, 0.25 ml PO every 3 hours PRN for agitation/anxiety, restlessness, and uncontrolled seizures, with a start date of 5/19/26 and no stop date. R13’s June MAR showed lorazepam intensol oral concentrate 2 mg/ml, 0.25 ml PO every 3 hours PRN for anxiety, with a start date of 5/29/26 and no stop date. The pharmacist made similar recommendations for both residents, citing the federal requirement that PRN psychotropic orders are limited to 14 days unless the prescriber documents the rationale and specific duration for extension. The DON stated on 6/24/26 that all PRN antipsychotic medications have to have a stop date of no more than 14 days.
Delayed response to change of condition and failure to apply ordered leg wraps
Penalty
Summary
The facility failed to treat a resident experiencing a change of condition in a timely manner. R2 was admitted with diagnoses including respiratory failure, pneumonia, and hypertensive heart disease. On 6/19/26 in the evening, an LPN documented that R2 was lethargic, difficult to arouse, warm and clammy, diaphoretic, congested with an occasional moist cough, had a pulse oximetry reading of 88-89% on 2L oxygen by nasal cannula, and had a blood pressure of 88/68. The RN supervisor was notified and evaluated the resident. The same LPN documented attempts to contact the resident’s POA and then another family member, with continued monitoring while waiting for a response. The LPN did not text the NP regarding the condition change until 11:15 PM, and new orders to send the resident to the ER were not received until 11:45 PM. The resident was not transported to the hospital until 1:20 AM, about 5 hours after the initial assessment. Hospital documentation on 6/20/26 showed the resident was admitted with hypoxia, altered mental status, sepsis, and elevated troponin. The facility also failed to ensure ordered ace wraps were applied to residents’ legs. R23 stated her leg wraps were not on after being transferred to her recliner, and later said they should be applied every day in the morning and removed at night. The next day, R23 again stated the wraps had not been put on after she reported this to staff. R95 was observed with swollen lower legs and feet, with two elastic wraps rolled up on the table, and the wraps were still not applied later that day. The DON stated the wraps should be placed on as ordered. Both residents had physician orders for elastic wraps to both lower legs in the morning and off at bedtime.
Failure to Provide Pressure Injury Care and Offloading
Penalty
Summary
The facility failed to ensure appropriate assessment, treatment, and care planning for a newly acquired pressure injury and failed to implement interventions to promote healing and prevent worsening of wounds for 2 residents reviewed for pressure injuries. One resident had diagnoses including hemiplegia, cerebral infarction, gastrostomy and colostomy status, aphasia, and dysphagia, and had an order to monitor and dress a right outer ankle wound. The resident was observed with the right ankle lying on the bed and not floated or elevated on multiple occasions, and during wound care the site was described as a circular reddened wound with a purple indentation in the center. The nurse did not measure the wound during dressing change and did not attempt to float or elevate the ankle afterward, stating the resident had previously refused. The record contained only one wound observation tool documenting a facility-acquired unstaged pressure ulcer on the right outer ankle, with no additional observation tools available, no documented refusal of intervention to float the ankle, and no skin check documentation of education, notification, or clinical suggestions. The care plan was not updated to include the acquired pressure injury, and the facility’s pressure list did not include the resident. Another resident had diagnoses including a stage 3 pressure ulcer of the left elbow, intellectual disabilities, legal blindness, heart disease, and generalized anxiety. The wound physician note documented a stage 3 pressure wound to the left elbow with moderate serous drainage and orders for daily calcium alginate with bordered foam dressing and offloading with elbow pads. However, the resident was observed with an open area to the left elbow without a dressing in place, and later was lying in bed with no dressing and no elbow pads in place. A CNA stated the resident had a wound to the left elbow but had not seen the elbow pads and had not been told to put them on, and an LPN stated the resident was blind, had a wound to the left elbow, and should have a dressing in place.
Improper Positioning of Indwelling Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident’s indwelling drainage bag was positioned below the level of the bladder. R23’s face sheet listed diagnoses including neuromuscular dysfunction of bladder, polyneuropathy, chronic kidney disease, personal history of urinary tract infections, and presence of urogenital implants. On 6/22/26 at 1:30 PM, R23 was observed sitting in her wheelchair and was then transferred by two CNAs to her recliner chair using a mechanical stand lift. When R23 requested that her leg bag be emptied, the drainage bag was observed secured to the lower thigh, overlapping the kneecap, and not positioned downward below the bladder level. During the observation, V13 emptied urine into a urinal and did not secure the drainage cap, and urine was seen dripping down R23’s leg. When asked to check the cap, V13 stated, “Oops, I thought it was closed.” On 6/23/26 at 9:48 AM, V14 stated that CNAs change urinary drainage bags to leg bags and that leg bags should be used for residents who are ambulatory; V14 also stated drainage bags should be placed below the level of the bladder for urine to drain and to prevent infections. R23’s care plan identified an ADL deficit related to absence of balance with non-ambulatory status, an indwelling urinary catheter related to urinary retention, and an intervention to position the catheter bag and tubing below the level of the bladder. The care plan also noted treatment for a UTI on 5/1/26. The facility’s catheter care policy stated that leg bags may be used for ambulatory residents and should be attached to the resident’s thigh or calf with slack in the tubing to minimize pressure and retention.
Staff Failed to Respond Appropriately to Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure staff knew how to appropriately respond to, assess, and address behavioral symptoms in residents diagnosed with dementia. The report identifies three residents with dementia-related behaviors who were managed primarily through staff redirection, verbal correction, or PRN medication, rather than through consistent individualized behavioral approaches described in their care plans and the facility’s dementia care policy. One resident, who had dementia and agoraphobia with panic disorder and lived on a locked memory care unit, repeatedly wandered and attempted to exit through doors leading to an enclosed outdoor area. When she became upset and aggressive after being prevented from going outside, multiple staff members responded, and a nurse sought PRN medication to calm her down. Staff statements indicated they usually did not let her go outside or walk with her even though the area was available, and that they relied on PRN medication when she became upset. Her progress notes documented repeated aggressive and exit-seeking behaviors, and her care plan listed wandering and verbal aggression interventions, but the observed response centered on containment, redirection, and medication after escalation. Another resident with dementia and anxiety was observed in the dining room taking silverware from the table and wrapping it in a napkin and placing it in his shirt. A nurse responded in a loud, stern voice, repeatedly telling him not to do it and stating that all new silverware was needed because of him. The resident’s progress notes did not document this behavior, and his care plan did not address the specific utensil-taking behavior. A DON later stated the resident needed to be spoken to calmly because otherwise it would work him up more. A third resident with dementia was reported by his sister and staff to be wandering into female residents’ rooms, trying to remove his clothes, and becoming aggressive. Staff moved him to the medication room and told him not to hit staff, which reportedly escalated his behavior. The sister stated staff seemed shocked by his wandering despite his dementia and believed they lacked training on how to handle the behavior. The resident’s progress notes documented wandering into female peers’ rooms, undressing, and becoming combative, while his care plan addressed general behavior issues with calm approach, diversion, and removal from the situation, but the events described showed staff responses that were loud, reactive, and not aligned with those approaches.
Medication Administration Errors During Observed Pass
Penalty
Summary
Medication administration errors were identified during observation, interview, and record review, with 2 errors out of 40 opportunities resulting in a 5% error rate. The deficiency involved 2 of 6 residents observed during the medication pass, including R113 and R120. The facility failed to administer medications as ordered and did not follow the six rights of medication administration, including right drug, right dosage, right route, right time, and right documentation. For R113, an LPN administered a PRN antipsychotic medication from the resident’s home medication supply. The bottle was labeled Seroquel 25 mg, while the resident’s order was for quetiapine fumarate 50 mg, 1 tablet by mouth every 24 hours as needed for agitation at bedtime. The LPN stated she would give 2 tablets because the order was for 50 mg, and she observed that there were 2 different pills in the bottle; she was unsure of one pill and used her phone to google it before deciding to give the medication because google confirmed it was Seroquel. For R120, the LPN administered noon medications including Wellbutrin 75 mg, Tylenol 500 mg, metformin 500 mg, senna plus, tramadol 50 mg, and 0.25 ml of lorazepam, but did not state that any medications had already been given or held. The MAR also showed Voltaren gel 1% to both knees four times daily, and the gel was not applied during the observed pass; the LPN later stated she had already given the Voltaren gel before the medication pass.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled with an open date, discarded once expired, and verified before use when residents’ home medications were being used. During observation, an LPN was administering a PRN antipsychotic medication to one resident and stated the resident was using home medications. The resident’s Seroquel 25 mg bottle from a local pharmacy contained two different pills, and the resident’s folic acid and metoprolol bottles also contained two different pills. The LPN stated she had not noticed the mixed pills and said she had been told to use the resident’s home medications until they were gone. The resident’s June MAR listed physician orders for Seroquel 50 mg PRN, folic acid 1 mg, and metoprolol 50 mg. The survey also found two insulin pens in use without proper dating and beyond the expected use period. One resident’s long-acting insulin pen was opened and being used, but there was no open date on the pen; the LPN stated insulin pens are only good for 28 days and it was probably expired and should be thrown away. Another resident’s short-acting insulin pen was opened and dated more than 28 days earlier; the LPN stated the pen was expired and should be thrown away and that nurses are supposed to label pens when opened. Facility med room and nursing station inspection reports from February and March 2026 also documented concerns with medications being used within expiration dates and not being labeled with open dates. The facility policy stated all medications used in the facility will be labeled in accordance with current state and federal regulations and accepted pharmaceutical principles and practices.
Failure to Follow EBP, PPE, and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that staff followed infection prevention and control practices, including the use of PPE and hand hygiene, for one resident on enhanced barrier precautions related to Klebsiella pneumoniae in the urine. The resident’s care plan documented the need for extra hand hygiene and cleaning of supplies. On 6/22/2026, an EBP sign was posted outside the resident’s room, but a CNA brought a cart containing meal trays into the room and touched the resident’s pillow, sheets, and bed controls without wearing PPE. The CNA then picked up a towel from the floor and placed it on the cart. After leaving the room, the CNA wheeled the same cart into the common area and removed another resident’s meal tray from it to deliver the tray, without performing hand hygiene before or after contact with the resident’s environment, upon exiting the room, or before handling the other resident’s meal tray. No sanitization of the cart was observed. The CNA stated not knowing why the resident was on EBP and confirmed the cart should have remained outside the room and hand hygiene should have been performed. The unit coordinator stated that carts should remain outside rooms with isolation precautions, gloves should be worn when delivering trays as a precaution, hand hygiene should be performed upon exiting the room, and the towel should not have been placed on the meal tray cart.
Failure to Offer Maintenance Ambulation Assistance
Penalty
Summary
The facility failed to ensure a resident with limited mobility was offered a maintenance ambulation plan to maintain the ability to walk. The resident stated that staff did not assist him to walk in the hallway and said he tries to walk daily to maintain his ability to walk. His care plan, initiated on 4/23/26, identified limited mobility and included a goal for a maintenance ambulation plan, with floor staff to offer ambulation assistance in the hallway once a day for 5-7 days a week. The care plan also noted that the resident refused to use his call light to request walking assistance. On 5/17/26, the resident did not receive the expected offer to walk. The restorative nurse stated that staff did not offer the resident his maintenance ambulation plan that day and that the CNA caring for him assumed the resident would ask to be walked, even though the resident would not ask. The resident’s task documentation for that day showed the ambulation task as completed, but the restorative nurse said that documentation was not correct. The resident’s mobility maintenance audit indicated he did not walk on 5/17/26, and the progress note stated the resident did not ask to be walked, so the CNA assumed he did not want to walk.
Medication given from another resident’s card
Penalty
Summary
The facility failed to ensure medications were given as ordered for 1 of 3 residents reviewed for medication administration. One resident had quetiapine 12.5 mg ordered in the morning, but the medication was ordered and discontinued on 11/19/25 after the power of attorney did not consent to it. Another resident was admitted with diagnoses including generalized anxiety disorder and had quetiapine 12.5 mg ordered at bedtime on 4/17/26. Her MAR showed she began receiving the medication on 4/17/26, but the pharmacy proof of delivery showed the quetiapine tablets were not delivered until 4/26/26, and the facility stock supply receipt showed only one dose was taken on 4/22/26. On 5/13/26, an LPN found a card of quetiapine for one resident in the medication cart with a note from an RN directing that the card be used for the other resident until her supply arrived from the pharmacy. The LPN stated nurses are not allowed to use another resident’s medications for someone else and that the medication should have been obtained from stock cubex until the resident’s card arrived. The RN acknowledged she had taken the card from the return bin and used it for the other resident, stating she knew it was not the protocol and did not check the cubex for stock. The DON confirmed medication cards should only be used for the residents they are prescribed for, and the facility policy required the six rights of medication administration and comparison of the bubble pack with the MAR.
Failure to Provide Ordered Restorative Walking Program
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered restorative ambulation services to a resident with limited mobility and a documented restorative walking program. The resident, who has lower extremity weakness and recurring wounds, reported that he is supposed to be walked twice daily, historically at set times in the morning and afternoon by a restorative aide who was recently terminated. He stated that on two specific weekend days he was not walked at all and was not offered walking, and on a subsequent day he was not walked twice as planned. He filed a grievance stating that his walking rehabilitation schedule was not being followed and questioned whether his walking rehab would be continued. Staff interviews and record review confirmed that the resident had an active restorative ambulation program requiring walking 50 feet in the hallway with a wheeled walker and standby assist twice daily, with a preference for morning and afternoon walks, and that refusals were to be reported to the nurse and documented. Nursing leadership and the restorative nurse stated that, after the restorative aide left, floor CNAs were responsible for providing the twice-daily walks, but there would no longer be a set time. The unit coordinator indicated the resident was not scheduled for restorative services every other weekend and did not follow up with CNAs on the days the resident alleged he was not walked. CNAs assigned to the resident over that weekend reported they did not walk him and were unsure who was responsible for walking residents on restorative programs. Progress notes for the dates in question did not contain any documentation of the resident refusing walks, despite the care plan requirement to document refusals and notify the nurse.
Failure to Safely Use Mechanical Lift During Transfer Resulting in Resident Fall and Spinal Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer and adequate supervision during the use of a sit-to-stand mechanical lift, resulting in a resident fall and injury. The resident involved was cognitively impaired and care planned as being at risk for falls due to impaired cognition, obesity, and impaired balance. According to the incident report and staff interviews, two CNAs used a sit-to-stand lift to transfer the resident from bed to wheelchair. After the resident was placed in the wheelchair, one CNA left the room, even though the resident remained attached to the lift via a strap around his back. As the remaining CNA began to unhook the back strap from the lift, the resident leaned or laid back in the wheelchair, causing the wheelchair to flip backwards and the resident to land directly on his back. The facility’s Assistant DON stated that facility practice requires two staff members to remain with the resident until the resident is completely unhooked from the sit-to-stand lift and securely seated, with one staff operating the lift and the second stabilizing the resident and wheelchair. The facility’s written policy on “Safe Lifting and Movement of Residents, Including Mechanical Lifts” requires at least two CNAs for mechanical and stand lift transfers to safely move residents. In this incident, no one was holding the resident or the wheelchair while the strap was being disengaged, and one CNA had already left the room, contrary to facility expectations and policy. Following the fall, the resident complained of back pain over the next two days and was subsequently sent to the hospital, where a CT scan showed an acute, unstable hyperextension fracture of the eighth thoracic vertebra, attributed to the fall.
Failure to Notify Providers and Manage Worsening Pain After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to effectively manage and treat a cognitively impaired resident’s pain following a fall from a wheelchair. On 2/1/26, the resident fell backwards onto the floor while seated in a wheelchair during care, landing directly on his back. A nurse practitioner was notified by phone of the fall and ordered Tramadol 50 mg every four hours as needed for pain, in addition to the resident’s scheduled Tramadol three times daily. Progress notes for that day documented the fall and the new pain medication order but did not show that the resident was seen or assessed in person by a physician or nurse practitioner on 2/1/26. On 2/2/26, progress notes documented that the resident began complaining of increased back pain with movement, yelling when the head of bed was elevated or lowered or when staff assisted with repositioning. Nursing staff interviews confirmed that the resident stayed in bed, yelled with movement due to back pain, and refused cares because movement worsened his pain. Despite these observations of worsening pain and refusal of care, there was no documentation that the physician or nurse practitioner was notified on 2/2/26, and no evidence that the resident was seen or assessed by a provider that day. The nurse practitioner later stated she had been in the facility seeing other residents on that date but was not informed of the resident’s worsening pain. By 2/3/26, progress notes showed the resident continued to have back pain from the fall, was yelling out when staff attempted to provide care, and refused a shower, stating he hurt too badly. Nursing staff notified a nurse practitioner that morning regarding the resident’s condition and that he was yelling out in pain even when not being touched. The resident’s POA was also notified and requested that he be sent to the hospital. The resident was transferred by ambulance, and a hospital CT scan on 2/3/26 revealed an acute, unstable fracture of the eighth thoracic vertebra consistent with a hyperextension injury from the fall. The facility’s own pain management policy required reassessment and revision of the pain management regimen and plan of care when pain was not adequately controlled, but the record showed no timely provider notification or adjustment of treatment in response to the resident’s worsening pain on 2/1/26 and 2/2/26.
Failure to Complete Ordered Lumbar X-Ray and Notify Providers After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered radiology services were completed or alternative arrangements made after a resident sustained a fall with resulting back pain. The resident fell backwards from a wheelchair onto the floor, landing on his back, and subsequently complained of lower back pain. A nurse practitioner ordered a lumbar X-ray to be completed in the facility, with a physician order specifying 2–3 views of the lower lumbar area related to trauma and pain. When the X-ray technician arrived, the study could not be completed due to weight concerns and the technician stated that an additional tech and a special board would be needed to hold the resident. The X-ray staff did not return to complete the ordered study, and the lumbar X-ray was never performed in the facility. The resident continued to complain of back pain and was later transferred to a local hospital due to worsening pain, where he was diagnosed with a thoracic vertebral fracture. Facility progress notes for the day the X-ray attempt failed contained no documentation that the physician, nurse practitioners, or the resident’s POA were notified that the ordered X-ray was not completed. An LPN confirmed she did not notify the POA or either nurse practitioner that the X-ray was not done. The POA and both nurse practitioners reported they were not informed until the following day, shortly before or on the day the resident was sent to the hospital, that the X-ray had not been completed as ordered. This failure occurred despite a facility policy stating it will provide appropriate diagnostic services, including radiology, in accordance with state and federal guidelines.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, malnutrition, and other significant diagnoses was found to have not received timely incontinence care. The resident required total to substantial staff assistance for activities of daily living and was always incontinent of urine and bowel, with a documented risk for skin breakdown. During an observation, a certified nurse aide responded to the resident's request to be changed and discovered that the resident's bed linens, incontinence brief, blue pad, bed sheet, bed alarm safety pad, and mattress were all saturated with urine. The resident expressed discomfort, stating she was cold and uncomfortable, and could not recall when she was last changed. The aide was unaware of the last time the resident was checked or changed and noted that the situation was inappropriate, attributing it to possible inexperience among newer staff. The resident's care plan required staff to check and change her incontinence products upon waking, before and after meals, before bed, during nighttime checks, per request, and as needed. The Director of Nurses confirmed that residents should be checked at least every two hours and that being left in urine is a dignity issue and increases the risk for skin breakdown and infection. The facility's policy also stated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene. Despite these protocols, the resident was left in a saturated state, indicating a failure to provide timely and adequate incontinence care.
Failure to Maintain Physician-Ordered Pressure Ulcer Dressing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral palsy, chronic obstructive pulmonary disease, polyneuropathy, obesity, osteoarthritis, seizures, peripheral vascular disease, and heart failure, did not have a physician-ordered pressure ulcer dressing in place. The resident had a stage III pressure ulcer on the sacrum, with specific orders for wound care to be performed three times a week and as needed. Documentation indicated that the dressing change was signed off as completed, but during an observation by surveyors, no dressing was found on the resident's pressure wound, nor was it present in the brief. Certified Nursing Assistants confirmed that no dressing was in place during the provision of incontinent care. The resident's care plan and facility policy required adherence to physician orders for wound care and communication of interventions to all relevant staff. The resident was dependent on staff for activities of daily living, including repositioning and incontinence care, and was at high risk for pressure ulcers. Despite these documented needs and orders, the required dressing was not applied or maintained as ordered, resulting in a failure to provide appropriate pressure ulcer care.
Failure to Implement Fall Prevention Interventions and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for multiple residents identified as being at risk for falls. One resident with a history of stroke, hemiplegia, dementia, and other significant medical conditions was care planned to have a bed alarm in place due to her high fall risk. However, during observation, the bed alarm was found on top of the blankets and not under the resident, rendering it ineffective. This same resident had a recent unwitnessed fall in her room, and documentation indicated that the bed alarm was not activated at the time of the incident. Two additional residents, both with dementia and a history of falls, were observed in their rooms without their call lights within reach. One resident's call light was on an empty bed next to him, and he was unable to locate it, stating he had previously fallen while trying to get up. The other resident's call light was found on the floor, out of reach, and he was unaware of its location. Staff interviews confirmed that call lights should be accessible to residents at all times, and care plans for both residents specified that call lights should be within reach and that residents should be encouraged to use them for assistance. The facility's own policies on fall prevention and call light accessibility require that interventions such as bed alarms and accessible call lights be in place for residents at risk of falls. Despite these policies and individualized care plans, staff failed to ensure that these safety measures were consistently implemented, resulting in residents being left without necessary fall prevention interventions.
Catheter Bag Improperly Positioned Above Bladder Level
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, dementia, and a stage IV pressure injury was observed with an indwelling urinary catheter bag positioned above the level of her bladder. During wound care provided by an LPN and a Unit Manager/RN, the resident was in bed with her feet elevated, and the catheter drainage bag was attached to the footboard, even with her feet and above her bladder. The drainage tubing was on the bed, and during repositioning, urine was seen flowing back toward the resident and away from the bag. After the wound care was completed, the staff exited the room without repositioning the catheter bag and tubing below the bladder level. Interview with the LPN confirmed that the catheter bag was incorrectly placed and acknowledged that it should have been hanging lower, off the bed frame, to prevent backflow. The resident's care plan specifically directed that the catheter bag and tubing be positioned below the level of the bladder, and the facility's catheter care policy also required this practice to discourage backflow of urine. The failure to follow these protocols resulted in the identified deficiency.
Failure to Verify Feeding Tube Placement Using Approved Method
Penalty
Summary
A deficiency occurred when staff failed to verify the placement of a gastric feeding tube using an approved method prior to administering medications and a bolus feeding to a resident. The resident in question had multiple diagnoses, including colon cancer, stroke, high blood pressure, and hemiplegia, and was dependent on staff for all care, including tube feeding. During observation, a registered nurse checked tube placement by injecting air into the tube and listening with a stethoscope, a method that is no longer considered best practice. The nurse then proceeded to administer medications and feeding through the tube. Interviews with nursing staff revealed uncertainty regarding the facility's policy for verifying tube placement, with both the nurse involved and another RN unable to locate a clear policy. The Director of Nursing acknowledged that the current policy was vague and in the process of being updated, and confirmed that air insufflation is not the best practice. Facility guidelines and care plans required verification of tube placement before administering feedings or medications but did not specify the method to be used.
Failure to Administer Medications as Ordered and Lacking Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for two residents. In the first case, a resident with multiple diagnoses including dementia, diabetes, and chronic kidney disease was found with four assorted pills left on her bedside table, which she identified as her morning medications. She reported that the nurse leaves her medications for her to take at her convenience, but she was unable to identify the pills or their purpose. Review of her records showed no assessment or documentation indicating she was capable of self-administering her medications, nor was there any care plan reflecting self-administration, contrary to facility policy. In the second case, a resident with colon cancer, stroke, and hemiplegia, who is dependent on staff for all care, did not receive a prescribed dose of lisinopril as ordered. The nurse prepared and administered several medications but omitted the lisinopril, which was scheduled for the morning medication pass. The MAR showed the time for lisinopril administration had recently changed, and the nurse was unsure if it had been given. The MAR was not signed for the administration of lisinopril, and the DON confirmed that the MAR should be referenced to ensure all medications are given as ordered. Facility policy requires verification of medications against the MAR prior to administration.
Failure to Use Required PPE During High-Contact Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow enhanced barrier precautions while providing care to a resident with multiple complex medical conditions, including a stage III pressure ulcer. During observed episodes of incontinent care and a dressing change, certified nursing assistants and a licensed practical nurse wore gloves but did not don gowns, despite clear signage and care plan instructions requiring both gloves and gowns for high-contact activities under enhanced barrier precautions. The care plan and posted signage specified that gowns and gloves were necessary for activities such as changing briefs, providing hygiene, and wound care for residents on these precautions. The facility's policies, as well as statements from the unit manager, confirmed that staff are required to wear gowns and gloves when providing high-contact care to residents on enhanced barrier precautions. Documentation showed that the resident had an active order for wound care and was assessed with a stage III pressure ulcer. Despite these requirements and the presence of clear instructions, staff did not comply with the expected infection control protocols during the observed care events.
Resident Abuse Incident Involving Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving a resident with Alzheimer's disease, severe dementia with agitation, and other conditions. The resident, who has a history of becoming physically aggressive due to anger, dementia, and poor impulse control, was involved in an incident where a housekeeper, V9, attempted to physically restrain him. The resident was walking around the facility when V9 tried to direct him to a chair by grabbing his wrists and walking him backwards, resulting in the resident falling. Multiple staff members, including a CNA, LPN, and unit attendant, witnessed the incident and confirmed that V9 held the resident's wrists and forcefully walked him backwards, which led to the fall. The LPN and other staff members indicated that the appropriate response to the resident's agitation should have been to walk away and allow the resident to calm down, rather than physically restraining him. The incident was considered abuse by the staff, as it involved the willful infliction of physical harm and mental anguish on the resident. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from abuse by anyone, including staff. The policy defines abuse as the willful infliction of injury or unreasonable confinement, which aligns with the actions taken by V9 during the incident. The Director of Nursing and the Administrator both acknowledged that V9's actions were inappropriate and constituted abuse, leading to V9's termination.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of resident-to-resident abuse were immediately reported and investigated. Specifically, an incident occurred where one resident (R2) hit another resident (R3) in the dining room, which was witnessed by several staff members, including a Unit Attendant (V5) and a CNA (V7). Despite these observations, the incident was not reported to the facility's administrator or documented as required by the facility's abuse policy. The policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a supervisor, who must then inform the administrator. However, the administrator (V1) and the current Director of Nursing (V2) were unaware of the incident, indicating a breakdown in communication and reporting procedures. Interviews with staff revealed that statements were taken by the former Assistant Director of Nursing (V18), but no formal investigation or report was completed or submitted to the proper authorities. The facility's administrator confirmed that no abuse allegations or investigations had been reported in the past two months, despite the incident occurring in September. This lack of documentation and failure to follow the established abuse reporting protocol resulted in a deficiency, as the facility could not provide any reports or documentation of an investigation regarding the incident between R2 and R3.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to ensure that a resident received a written grievance decision, as required by their grievance policy. The resident, who is diagnosed with peripheral neuropathy, Type 2 diabetes, obesity, heart failure, chronic kidney disease stage 3, and peripheral vascular disease, had filed grievances but only received verbal responses. During an interview, the resident expressed that he did not receive written responses to his grievances, despite requesting them. The facility's policy mandates that a written decision be provided to the resident at the conclusion of the grievance investigation. The resident's grievance dated 6/9/24 involved an incident of rude and disrespectful conversation with a staff member. The grievance specifically requested both a verbal and written response. However, the Director of Nursing informed the resident that written grievance resolutions were not provided, contradicting the facility's policy. The policy clearly outlines that the grievance official is responsible for issuing a written decision, including details such as the date received, investigation steps, findings, and any corrective actions taken.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place for a resident with a history of falls, resulting in the resident falling and fracturing her left hip. The resident, who had severe cognitive impairment and was dependent on staff for transfers, was supposed to have a chair alarm in her wheelchair as part of her care plan. However, on the morning of the incident, the chair alarm was not in place, as it had been left in a recliner the previous night. The incident occurred when a CNA transferred the resident to her wheelchair and left her at the nurses' station without realizing the chair alarm was missing. Shortly after, the resident was found sitting on the floor with her back against another resident's wheelchair. The CNA and LPN on duty confirmed that the chair alarm was not in the wheelchair at the time of the fall, which was supposed to alert staff when the resident attempted to get up. The Director of Nursing and other staff members acknowledged the importance of chair alarms in preventing falls, especially during shifts with fewer staff. The resident's care plan clearly indicated the need for a chair alarm due to her risk factors, including confusion, weakness, and a history of falls. The lack of the chair alarm contributed to the delay in staff response, ultimately leading to the resident's fall and subsequent hip fracture.
Delay in Radiology Services for Resident Post-Fall
Penalty
Summary
The facility failed to provide timely radiology services for a resident who fell and was experiencing pain in her hip. The resident, who had a history of dementia, depression, and a left femur fracture, was found sitting on the floor with complaints of discomfort to her left hip. An X-ray was ordered after the fall, but it was not conducted until nearly 36 hours later, revealing acute fractures. Interviews with staff indicated that the contracted X-ray company typically takes 24 to 48 hours to perform X-rays, and the family was not informed of the potential delay or given the option to send the resident out for a quicker evaluation. The resident's Power of Attorney was not made aware of the delay in obtaining the X-ray and was not offered the option to have the resident sent out for immediate evaluation. The Director of Nursing acknowledged that ideally, X-rays should be done within 24 hours, but the facility had no control over the contracted imaging company's timeline. The facility's change in condition policy indicated that X-rays and labs might take up to 24 hours, but this was not communicated effectively to the resident's family, leading to a delay in diagnosis and treatment.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 214 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avira Health Pavilion | 0.6 mi | ★★★★★ | 1 | 0 |
| Rock River Health Care | 0.6 mi | ★★★★★ | 14 | 1 |
| Willows Health Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 2.1 mi | ★★★★★ | 0 | 0 |
| Amberwood Care Centre | 2.1 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.