Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency At Bluffs Park during CMS and state inspections, most recent first.
A resident with hypotension, muscle wasting, poor strength and balance, and documented dizziness and lightheadedness had a care plan and therapy-to-nursing instructions requiring substantial/maximal assist of two staff, use of a sit-to-stand lift for transfers, and ambulation with a rolling walker in therapy only. Despite this, a CNA assisted the resident out of bed and ambulated him to the bathroom with only a walker and grippy socks, without a gait belt, without a second staff member, and without checking the Kardex. While the CNA turned to open the bathroom door, the resident fell backward, was initially unresponsive, and was later found to have multiple skull fractures, subdural hematoma, and brain compression. Interviews showed that some nursing staff believed the resident was a one-person assist and were unaware of recent hypotension and dizziness, while the DON confirmed that the care plan and Kardex requiring two-person assist and sit-to-stand lift were not followed, and the death certificate attributed death to complications of blunt force head trauma from the fall.
A resident with hypotension, muscle wasting, liver cell carcinoma, impaired balance, and documented lower extremity impairment had a care plan and Kardex indicating substantial/maximal assist with two staff, use of a sit-to-stand lift for transfers, wheelchair for ambulation, and ambulation with a rolling walker in therapy only due to poor strength, balance, and fall risk. A CNA, without checking the Kardex, assisted the resident out of bed using only a walker and grippy socks, with standby assist and no gait belt or lift, and attempted to walk the resident to the bathroom. When the CNA turned to open the bathroom door, the resident fell backward, was initially unresponsive, and was later found to have skull fractures and a subdural hematoma with brain compression. The death certificate listed complications of blunt force head trauma from a fall at the nursing home as the immediate cause of death, and interviews with staff and the DON confirmed that the resident’s care plan was not followed and that nursing staff had ambulated the resident despite the documented restrictions.
Surveyors found that food service equipment, including a juice machine, stove/oven, can opener, mixer table, and refrigerator, was not properly cleaned and had accumulated food residue. Additionally, the dish machine was operating below required sanitizing temperatures, and some equipment was in disrepair, such as loose stove handles and a leaking sink faucet. These deficiencies affected 58 residents and increased the risk of cross-contamination and bacterial growth.
Surveyors identified widespread deficiencies in cleaning and maintenance, including soiled ventilation grills, damaged chairs exposing inner padding, and missing or broken atmospheric vacuum breakers in multiple areas. These issues were not documented in the facility's maintenance work order system, despite policies requiring ongoing monitoring and cleaning.
Multiple residents and their families reported incidents where staff denied timely toileting assistance, made dismissive remarks, or failed to provide appropriate care, resulting in emotional harm and humiliation. Despite these grievances, facility leadership did not recognize or report these events as abuse or neglect to the state agency, instead treating them as customer service issues and failing to follow required abuse reporting protocols.
Multiple residents reported grievances involving staff telling them to use the bathroom in their briefs, denying assistance with toileting, and making dismissive remarks. These complaints were not recognized as potential abuse or neglect, and no investigations were conducted. Instead, the facility treated the issues as customer service concerns, resulting in emotional distress and a lack of appropriate follow-up for the affected residents.
Multiple residents experienced significant delays in call light response and pain medication administration due to insufficient nursing staff, with CNAs and LPNs reporting unmanageable workloads and inability to take breaks. Residents described waiting up to an hour for assistance, and staff acknowledged instructing residents to use briefs instead of providing timely toileting help. These staffing shortages led to ongoing concerns about unmet care needs and delays in essential services.
A resident with cognitive impairment was found resting in bed with un-bagged, feces-smeared linen placed on a pillow on a nearby recliner, just a few feet from their face. The soiled linen remained there for over 30 minutes. Staff interviews confirmed that protocol requires immediate bagging and removal of soiled linen, and that leaving it un-bagged on resident furniture is not acceptable.
Three residents experienced emotional distress after being told by CNAs to use the bathroom in their briefs due to staff time constraints, rather than being assisted to the toilet or offered their own underwear. These incidents, which were documented in grievances and confirmed by facility leadership, resulted in feelings of embarrassment, humiliation, and being devalued.
A resident with cognitive intactness and mobility issues experienced multiple room changes without receiving advance written notice as required. Documentation showed only two notifications for four room changes, and the social worker was unable to locate the missing notifications.
A resident with muscle wasting, atrophy, and anoxic brain damage, who was cognitively intact but dependent on staff for transfers and had limited hand use, was observed using a seatbelt on a motorized wheelchair that he could not independently release. Staff confirmed the resident's inability to unlatch the seatbelt, and no prior assessment of the seatbelt as a physical restraint was documented until after surveyor intervention.
A resident with mobility difficulties and intact cognition experienced missed and inappropriately timed showers due to frequent room changes and poor communication from staff. Showers were sometimes offered late in the evening or after dressing changes, leading to refusals, and documentation of refusals was inconsistent with facility expectations.
A resident with severe physical limitations fell and sustained a head injury after being transferred to a motorized wheelchair with the armrest left up. Staff involved in the transfer were not adequately trained on the resident's specific needs, and the resident was left unsupervised, resulting in the fall.
A resident with a history of spinal fusion and dialysis dependence did not receive Occupational Therapy (OT) services as ordered, with therapy staff citing scheduling conflicts and staffing shortages. Despite physician orders and an OT evaluation specifying frequent therapy, the resident went several days without receiving OT, as confirmed by service logs and staff interviews.
Staff did not consistently follow PPE protocols and hand hygiene practices for residents on Transmission-Based Precautions. For example, a resident on droplet precautions for suspected COVID-19 was cared for by staff who failed to wear required eye protection and did not remove masks as per protocol. Additionally, an LPN did not perform hand hygiene before or after medication administration, nor did he change his mask when required, including when caring for a resident on contact precautions for COVID-19.
The facility did not implement an effective QAPI plan to address allegations of abuse from resident grievances. Fifteen grievances were not identified as abuse, and the QAPI committee did not discuss or recognize these concerns, despite policy requiring review of resident concern logs.
A resident, admitted five days prior and cognitively intact, did not receive necessary oral care supplies, despite documentation indicating oral care was completed. The resident reported not having a toothbrush, toothpaste, or mouthwash since admission. A CNA was unable to locate these supplies in the resident's room, and the DON stated that new admissions should receive basic ADL supplies, including oral care items.
A resident with a history of cardiac and respiratory issues experienced a drop in oxygen levels, which was not followed up by the nursing staff. Despite alerts for low oxygen levels, there was no documented assessment or notification to the physician, leading to the resident being found unresponsive and requiring hospital transfer.
A facility failed to follow physician orders for a resident with urine retention, requiring bladder scans every six hours and catheterization if post-void residual exceeded 250 mL. Records showed multiple instances of non-compliance, with scans not completed and catheterizations performed without necessary results or below the threshold. The resident, cognitively intact, reported staff not performing scans before catheterization, confirmed by the DON.
A facility failed to notify a physician of abnormal urine culture results for a resident with urine retention. The resident's urinalysis showed a pending culture, and a Nurse Practitioner noted the positive urinalysis but awaited culture results as the resident was asymptomatic. The culture, positive for Klebsiella pneumoniae and E. coli, was not obtained until much later, with no documentation of physician notification or acknowledgment.
A facility failed to document urine culture results in a resident's medical record. The resident, admitted with urine retention, had a urinalysis indicating a pending culture. Despite a positive urinalysis noted by an NP, the culture results were not recorded. The results, showing Klebsiella pneumoniae and E. coli, were only retrieved months later upon request. The DON noted the use of a separate system for lab results.
The facility failed to maintain sanitary conditions in the kitchen, as dietary staff did not use hand barriers to shut off faucets after washing their hands. This non-compliance with the hand hygiene policy and the U.S. Public Health Service 2017 Food Code increased the potential for cross-contamination and foodborne illness, affecting 54 residents who receive meal services.
The facility failed to provide sufficient staff to meet residents' needs, resulting in delayed call light responses and unmet care needs. Multiple residents and family members reported long wait times for assistance, with some residents experiencing significant delays in receiving help for toileting and other needs. Language barriers further exacerbated the issue for non-English speaking residents.
The facility failed to maintain a safe, functional, and sanitary environment for 56 residents and staff. Dust and debris were found in the dietary storage closet, physical therapy cold compresses were stored in a food-designated freezer, and lift batteries and charging stations were kept in soiled utility rooms. The Housekeeping Supervisor acknowledged the improper storage and agreed to relocate the items.
The facility failed to maintain the dignity of two residents, leading to feelings of frustration and decreased self-worth. One resident was left without assistance after attempting to communicate in a different language, while another had to wait up to an hour for help and was dismissed when calling out for assistance.
A resident experienced dissatisfaction and reduced independence due to the facility's failure to provide timely repair services for her power wheelchair. Despite notifying the social worker months ago, no follow-up was conducted, and the issue was only recently addressed by the new Therapy Director and Social Worker. The Director of Nursing acknowledged the delay and lack of communication among staff.
The facility failed to accurately complete MDS assessments for two residents, leading to potential inaccuracies in care plans. One resident with profound hearing loss was documented as having adequate hearing, and another resident with severe mental illness was incorrectly coded as not having a serious mental illness. These errors were acknowledged by the social worker.
A resident with multiple medical conditions and a language barrier experienced repeated falls due to the facility's failure to implement comprehensive care plans and ensure effective communication. The resident's call light was often out of reach, and staff were unsure about using translation services, leading to unmet care needs and continued falls.
A resident with multiple medical conditions and a primary language of Romanian experienced repeated falls and unmet needs due to the facility's failure to utilize available translation services and communication tools. Staff were observed and interviewed, revealing a lack of awareness and use of these services, leading to significant deficiencies in care.
The facility failed to ensure appropriate contracture management for a resident with multiple medical conditions, including an amputation and acquired club foot. Despite physician orders and POC documentation for daily ROM exercises, there was no documentation of completion or refusal for the last 30 days. Staff interviews revealed that the resident had refused ROM in the past, leading to a lack of follow-through on prescribed exercises.
A resident with multiple diagnoses experienced recurrent falls due to the facility's failure to consistently follow care plan interventions and address communication barriers. Despite having a care plan that included non-skid footwear, call light accessibility, and two-hour toileting, the resident's falls continued. The resident's language barrier further complicated effective communication, and staff did not consistently use available translation services or communication tools.
The facility failed to administer pain medications as ordered for two residents, resulting in increased pain and unmanaged pain. One resident experienced frequent delays in receiving Morphine Sulfate ER, while another faced severe pain and withdrawal symptoms due to delays in receiving Fentanyl and Gabapentin. Staff acknowledged the deficiencies and the lack of proper documentation.
The facility failed to ensure proper storage of medications for two residents, leading to potential unauthorized access and medication errors. One resident was found with inhalers on her bed, and another with inhalers and eye drops on her windowsill. Both residents did not have completed assessments for self-administration, and their medications were not stored in a lockbox as required.
The facility failed to justify the use of an antipsychotic medication for a resident with visual hallucinations, adjustment disorder with depressed mood, and dementia. Despite multiple dose reductions and recommendations for further GDRs, the facility did not document adequate indications for the medication's use, nor did they attempt further GDRs. Interviews with staff revealed inconsistencies in the documentation and monitoring of the resident's symptoms.
Failure to Follow Care Plan and Therapy Restrictions Leads to Fatal Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall and follow the resident’s care plan and therapy-to-nursing instructions, resulting in a major injury. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma. An MDS assessment showed intact cognition but documented lower extremity impairment on one side and a need for substantial/maximal assistance for bed mobility and sit-to-stand, and dependence for toilet transfers and walking 10 feet. Therapy evaluations and progress notes documented poor strength and balance, generalized weakness, dizziness, lightheadedness, episodes of hypotension, and a need for maximal assistance of two staff for transfers, sit-to-stand, and ambulation. Therapy-to-nursing communication and the care plan specified that ambulation with a rolling walker was to occur in therapy only, that transfers required two-person substantial/maximal assistance with a sit-to-stand lift, and that toilet transfers required substantial/maximal assistance. Despite these documented needs, on the morning of the fall the resident’s call light was answered by a CNA who assisted the resident out of bed and ambulated him to the bathroom using only a walker and grippy socks, without a gait belt or sit-to-stand lift, and without a second staff member. The CNA reported that she did not check the Kardex for the resident’s required level of assistance because she had taken care of him before and did not think to check, even though she was aware that the Kardex should be used to determine assistance levels. While the resident was standing and the CNA turned away to open the bathroom door, she heard a loud sound and turned back to find the resident on the floor on his back and initially unresponsive. The incident report and nursing notes documented that the resident fell flat on his back while transferring to the bathroom, went unconscious, and was later noted to be lethargic with nonreactive pupils and a high PAINAD score indicating significant pain behaviors. Clinical records and interviews further showed that nursing staff were not consistently aware of or following the resident’s documented risks and limitations. Physical therapy notes recorded very low blood pressure readings in standing and sitting, and the nurse practitioner documented generalized weakness, gait instability, dizziness, and lightheadedness, with orthostatic vital signs later confirming significant blood pressure changes with position. A floor nurse who had previously cared for the resident stated that he walked with two staff and a walker and needed more assistance getting off the toilet, but the nurse on duty at the time of the fall believed the resident was a one-person assist and was unaware of recent dizziness or low blood pressure. The DON confirmed that the care plan and Kardex required two-person assistance, sit-to-stand lift for transfers, and ambulation with therapy only, and that the resident had been ambulated by nursing staff contrary to these directives. The fall resulted in multiple skull fractures, subdural hematoma, brain compression, and was listed on the death certificate as complications of blunt force head trauma from a fall in the nursing home.
Failure to Follow Care Plan for High-Risk Resident During Ambulation and Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow an existing care plan for a resident with significant functional limitations and identified fall risk. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma, and had intact cognition per an MDS assessment. The MDS and therapy assessments documented lower extremity impairment, a need for substantial/maximal assistance for bed mobility and sit-to-stand, dependence for toilet transfers and walking, and poor strength and balance. Therapy-to-nursing communication and the Kardex specified that the resident required substantial/maximal assistance, use of a sit-to-stand lift for transfers, wheelchair for ambulation, and that ambulation with a rolling walker was to occur in therapy only due to the level of assistance and safety cues required. Despite these documented needs and care plan interventions, on the morning of 11/15/2025 a CNA responded to the resident’s call light and assisted the resident out of bed using only a walker and grippy socks, without a gait belt or other assistive devices, and without checking the Kardex. The CNA attempted to walk the resident to the bathroom with standby assist, turned away to open the bathroom door, and then heard a loud sound. When she turned back, the resident was found on the floor on his back and initially unresponsive. The incident report and subsequent interviews confirmed that the resident had been ambulated by nursing staff, contrary to the care plan that required two-person substantial/maximal assistance with a sit-to-stand lift for transfers and specified that ambulation with a rolling walker was to occur in therapy only. Following the fall, the resident was noted to have a high PAINAD score with signs of pain, lethargy, and injuries including a skull fracture and subdural hematoma with brain compression. The death certificate later documented the immediate cause of death as complications of blunt force head trauma from a fall, with the place of injury identified as the nursing home. Interviews with the CNA, an LPN, and the DON confirmed that staff were expected to use the care plan or Kardex to determine required assistance levels, that the care plan was not followed at the time of the incident, and that the resident had previously ambulated with nursing staff despite the documented restrictions and identified fall risk.
Failure to Maintain and Sanitize Food Service Equipment
Penalty
Summary
Surveyors observed multiple instances of inadequate cleaning and maintenance of food service equipment affecting 58 residents. During an initial tour of the kitchen, several pieces of equipment, including the juice machine, Vulcan stove/oven, can opener assembly, stand mixer support table, and refrigerator, were found with accumulated and encrusted food residue. The stove/oven door handles were also noted to be loose, and the food preparation sink faucet assembly was leaking and could not be fully shut off. These conditions were confirmed by the Dietary Manager, who acknowledged the need for cleaning and repairs. Further review revealed that the mechanical dish machine's wash temperature was below the required standard, with a digital display reading 130.1°F during the cleaning cycle, which does not meet the minimum temperature requirements for effective sanitization as outlined in the FDA Model Food Code. The Registered Dietician confirmed that the facility had a contractual service for maintaining the dish machine. Policy and procedure documents reviewed indicated that malfunctions and repair needs should be reported promptly to maintenance and the administrator, and that cleaning and sanitizing of food contact surfaces should occur after each use and when contamination is possible. Despite these policies, the observed conditions demonstrated a failure to maintain food service equipment in a clean and sanitary state, as well as a failure to ensure timely repairs and proper functioning of essential kitchen equipment. These deficiencies increased the likelihood of cross-contamination and bacterial harborage, directly impacting the safety and quality of food served to residents.
Failure to Maintain Cleanliness and Physical Plant Integrity
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 60 residents. During an environmental tour, multiple areas were observed with soiled and encrusted dust/dirt deposits on return-air-exhaust ventilation grills, including shower rooms, staff and public restrooms, and resident rooms. Additionally, several chairs in common areas and resident rooms were found to be damaged, with surfaces etched, scored, and exposing inner Styrofoam padding. In the kitchen storage room, a broken atmospheric vacuum breaker was noted on the mop sink faucet assembly, and several shower wand assemblies in resident rooms were missing atmospheric vacuum breakers. Interviews with the Maintenance Director revealed that the facility uses the TELS system for maintenance work orders. However, a review of the TELS work orders for the past 60 days showed no specific entries related to the observed maintenance concerns. The facility's policies for maintenance and housekeeping require ongoing monitoring and thorough cleaning of environmental surfaces, but these procedures were not followed as evidenced by the observed deficiencies. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, reduced air quality, and potential cross-connections between potable and non-potable water supplies. The findings were based on direct observations, interviews, and record reviews, with no documentation indicating that the identified issues had been previously addressed through the facility's maintenance system.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment for 14 residents were reported to the state agency as required. Multiple grievances were filed by residents and their family members, describing incidents where staff told residents to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported feeling humiliated, degraded, or emotionally harmed by these interactions. Some residents also described being denied showers, not being offered the option to wear their own underwear, or being left without timely care for personal needs. Despite these grievances, the facility's administrative staff, including the administrator and DON, did not identify these incidents as allegations of abuse. Instead, they categorized them as customer service or care concerns and addressed them through staff education or reassignment, without reporting them to the state agency as required by policy. The facility's grievance policy specified that concerns related to alleged abuse, neglect, or mistreatment should be immediately forwarded to supervisory staff, but this procedure was not followed in these cases. Interviews with the administrator and DON confirmed that they were aware of the grievances and the nature of the complaints but did not consider them to be abuse. As a result, none of the allegations were reported to the appropriate authorities, and the required investigation and reporting process was not initiated. The failure to recognize and report these allegations represents a breakdown in the facility's abuse reporting protocol and a violation of regulatory requirements.
Failure to Identify and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to identify and investigate allegations of abuse for 14 out of 14 residents who reported grievances that included potential abuse or neglect. Multiple residents and their family members submitted grievances describing incidents where staff told them to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported being humiliated, embarrassed, or feeling like they were not cared for, and some described being forced to self-transfer or forego showers and personal care due to staff inaction. Despite these grievances, the facility did not recognize the complaints as potential abuse or neglect, and no formal investigations were conducted. Instead, the facility treated these reports as customer service or staffing issues, providing staff education or reassigning staff without initiating abuse protocols. In some cases, there was no documented resolution at all. The administrator and DON both confirmed in interviews that they did not consider these grievances as allegations of abuse, even when residents described psychosocial harm or direct statements from staff instructing them to soil themselves due to lack of assistance. The affected residents included individuals who were cognitively intact and able to articulate their needs and experiences, as well as those who required assistance with activities of daily living. Several residents expressed emotional distress, humiliation, and a loss of dignity as a result of staff actions and the facility's failure to respond appropriately. The lack of investigation into these allegations represents a failure to protect residents from potential abuse and to comply with regulatory requirements for reporting and investigating such incidents.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs for multiple residents. Certified Nurse Aides (CNAs) reported being assigned up to 16 or more residents per shift, with their ability to keep up with care dependent on resident acuity. Several residents reported waiting 30 to 60 minutes or longer for staff assistance, particularly for pain medication and call light responses. One resident, who had a history of spinal fusion and was dependent on renal dialysis, reported multiple instances of waiting 45 minutes or more for pain medication, and another resident described similar delays during overnight hours. Residents also reported that delays in care negatively impacted their physical therapy progress and caused concerns about timely assistance during emergencies. Staff interviews corroborated these concerns, with CNAs and LPNs stating that the facility was understaffed and that it was difficult to find assistance for two-person transfers. CNAs reported being unable to take breaks due to staffing shortages and described being responsible for up to 30 residents when coworkers were unavailable. Some staff admitted to instructing residents to use the bathroom in their briefs as a time-saving measure. Residents and staff consistently reported that call light response times were inadequate, and these issues were repeatedly raised in Resident Council meetings without resolution.
Failure to Maintain Resident Dignity by Improper Handling of Soiled Linen
Penalty
Summary
A deficiency was identified when a resident with a compression fracture and moderate cognitive impairment was observed resting in bed with a pile of un-bagged, feces-smeared linen placed on a pillow on a recliner chair approximately 2 to 3 feet from the resident's face. The soiled linen remained in this position for at least 31 minutes. Interviews with a CNA and the Director of Nursing confirmed that facility protocol requires soiled linen to be immediately bagged and taken to the soiled utility room, and that there is no acceptable reason for soiled linen to be left un-bagged or placed on resident furniture. The incident occurred due to a failure to follow established procedures for handling soiled linen, resulting in a lack of dignity for the resident.
Failure to Maintain Resident Dignity and Honor Personal Preferences
Penalty
Summary
The facility failed to honor the dignity and personal preferences of three residents by not offering them the choice to use their own underwear instead of briefs, and by instructing them to use the bathroom in their briefs due to staff time constraints. One resident, who was cognitively intact and ambulatory with a walker, reported never being offered his own underwear, despite having several pairs in his dresser. He expressed embarrassment and distress at being made to wear briefs, which he did not use prior to admission, and recounted an incident where a CNA told him to have a bowel movement in his brief because staff did not have time to assist him to the toilet. Another resident reported a similar experience, stating that a CNA told her to use the bathroom in her brief due to lack of time. This resident had also filed a grievance about the incident, which was documented as a customer service issue rather than an allegation of abuse. The administrator and DON confirmed awareness of these grievances and acknowledged that staff had told residents to use their briefs when assistance was requested but not provided. A third resident, who was cognitively intact and required assistance for transfers, reported long call light response times and being told to have a bowel movement in his brief while in bed. This resident described the experience as humiliating and degrading, and subsequently began self-transferring to the bathroom to avoid similar incidents. He also filed a grievance regarding the incident but reported no appropriate follow-up or resolution. All three residents experienced emotional distress, including feelings of anger, embarrassment, and being devalued.
Failure to Provide Advance Written Notice for Room Changes
Penalty
Summary
The facility failed to provide advanced written notice prior to a room change for one resident. The resident, who was cognitively intact and had difficulty walking, reported experiencing several room changes without prior notification, with staff typically informing her of the move on the same day it occurred. Record review confirmed that the resident had four room changes since admission, but only two written notifications were documented. The social worker confirmed that staff are expected to inform residents and document these conversations, but was unable to locate the missing notifications for two of the room changes.
Failure to Assess Wheelchair Seatbelt as Potential Physical Restraint
Penalty
Summary
A deficiency occurred when the facility failed to assess whether a seatbelt used by a resident in a motorized wheelchair constituted a physical restraint. The resident, who had diagnoses including muscle wasting, atrophy, and anoxic brain damage, was cognitively intact but dependent on staff for transfers and had limited use of only one hand. Observations and interviews confirmed that the resident was unable to independently release the seatbelt and had never been asked if he could do so. Certified Nursing Assistants and the Therapy Director confirmed the resident's inability to unlatch the seatbelt. Although the Therapy Director reported that a physical restraint evaluation had been completed, no documentation could be found until after surveyor intervention, at which point an evaluation and a physician order for the seatbelt were created.
Failure to Offer and Complete Showers per Resident Preference
Penalty
Summary
The facility failed to ensure that showers were offered and completed according to the preferences of a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and had difficulty walking, reported experiencing multiple room changes without prior notice, which led to confusion about her scheduled shower days. As a result, she missed some scheduled showers and was offered showers at inconvenient times, such as late in the evening or after dressing changes, leading to refusals. The resident was unsure of her current shower schedule and denied refusing showers except when they were offered at unreasonable times. Documentation review showed several instances where the resident either refused showers due to lack of advance notice or because the timing was inappropriate. In some cases, refusals were not properly documented, and staff marked 'no' in the shower task without following the expected documentation process. The Director of Nursing confirmed that staff are required to document refusals in the medical record or on a shower sheet and that showers should be offered according to the established schedule.
Failure to Prevent Fall Due to Improper Wheelchair Transfer
Penalty
Summary
A deficiency occurred when staff failed to prevent a fall for a resident with significant physical impairments, including muscle wasting, atrophy, anoxic brain damage, and no trunk control. The resident was dependent on two staff members and a mechanical Hoyer lift for transfers and required the armrests of his motorized wheelchair to be down for safety. On the day of the incident, after being transferred to his wheelchair, the left armrest was left up, and the staff member left the room. As a result, the resident fell sideways out of the chair and sustained a head injury, requiring hospital transfer. The incident report confirmed that the fall was due to the armrest being left up during the transfer. Interviews with staff revealed that the CNA assisting with the transfer was not adequately trained on the specific requirements for transferring this resident into the motorized wheelchair, particularly regarding the necessity of ensuring the armrests were down. The CNA also indicated that she was assigned to a different hall and had to leave the room due to other duties, which contributed to the lack of supervision. The Director of Nursing confirmed that the fall occurred because the armrest was not down and the resident lacked core strength, leading to the accident.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
A deficiency was identified when a resident with a history of spinal fusion and dependence on renal dialysis did not receive Occupational Therapy (OT) services as ordered. The resident was admitted and readmitted to the facility, and their physician orders specified OT services six times per week for 12 weeks, while the OT evaluation indicated five times per week for 12 weeks. The resident reported receiving less therapy than ordered and expressed concern about being considered for discharge due to lack of progress, attributing this to insufficient therapy sessions. Observations confirmed the resident was wearing a cervical collar and was in bed at the time of review. Interviews with therapy staff revealed that therapy sessions were sometimes missed due to the resident's dialysis schedule and staffing limitations, with attempts made to adjust therapy around these constraints. The Therapy Director confirmed that OT services had not been provided since a specific date, despite the resident remaining on the OT caseload. Review of the OT Service Log corroborated that no OT services had been delivered for several days, indicating a failure to provide specialized rehabilitative services as required by the resident's care plan and physician orders.
Failure to Ensure Proper PPE Use and Hand Hygiene During Transmission-Based Precautions
Penalty
Summary
Staff failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for residents on Transmission-Based Precautions (TBP). In one instance, a resident with a history of chronic obstructive pulmonary disease and recent testing for COVID-19 was placed on droplet precautions. Observations revealed that staff members entered the resident's room wearing gowns, gloves, and N95 masks, but did not wear required eye protection. One staff member exited the room wearing both an N95 and a surgical mask, walked through the hallway without removing the masks as required, and later returned to the room with a face shield but only a surgical mask. The Director of Nursing confirmed that the facility's protocol required a gown, gloves, N95 mask, and face shield to be worn, with removal of gown and gloves before exiting and removal of the N95 mask immediately upon exit. The resident was not informed about the reason for TBP, and isolation was discontinued after a negative COVID-19 test. Additional observations showed that an LPN did not perform hand hygiene before or after administering medications to residents, including one on contact precautions for COVID-19. The LPN donned a gown and gloves but did not change or remove his surgical mask as required, and failed to perform hand hygiene before donning gloves, contrary to posted recommendations. These actions did not follow the facility's policy and procedures for PPE use and hand hygiene, increasing the risk of cross-contamination.
Failure to Address Abuse Allegations in QAPI Process
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement Committee (QAPI) plan to address allegations of abuse arising from resident grievances. Review of resident concern and grievance logs showed that, since June 2024, there were 15 grievances from 15 residents that were not identified as allegations of abuse. According to the facility's QAPI policy and procedure, resident concern summary logs were to be used for identifying improvement priorities, but these logs were not utilized to identify abuse concerns. During an interview, the administrator confirmed that the QAPI committee met monthly with all required members present, but no performance improvement plans were in place, and allegations of abuse had not been recognized as a concern by the committee. Review of the most recent QAPI meeting minutes showed no discussion or identification of abuse allegations, despite the presence of multiple resident concerns in the logs.
Failure to Provide Oral Care Supplies to Resident
Penalty
Summary
The facility failed to provide necessary oral care supplies to a resident, identified as R5, who was admitted five days prior and was cognitively intact with a Brief Interview Status (BIMS) score of 15 out of 15. Despite being documented as having completed oral care, R5 reported not receiving a toothbrush, toothpaste, or mouthwash since admission. Observations confirmed R5's claim, as they were seen self-ambulating and sitting on the edge of their bed without having received the necessary supplies. A Certified Nursing Assistant (CNA) believed R5 had the supplies but was unable to locate them in R5's room. The Director of Nursing (DON) stated that new admissions should receive a basin with basic ADL supplies, including oral care items.
Failure to Follow Up on Resident's Low Oxygen Levels
Penalty
Summary
The facility failed to follow up on a change in vital signs for a resident (R2) who was admitted with diagnoses including infection and inflammatory reaction due to cardiac and vascular devices, COPD, history of cardiac arrest, and acute respiratory failure with hypoxia. On 7/12/24, R2's oxygen level was documented as 90% at 9:00 AM, but later in the day, it dropped to 85% and then to 83% without any documented follow-up or assessment by the nursing staff. RN C, who worked the day shift, reported not being aware of the oxygen level below 90% and did not document any assessment or notify the physician. The medical record lacked documentation of any intervention or notification to the physician regarding the low oxygen levels. Later that evening, LPN D found R2 unresponsive with an oxygen level of 83% and other vital signs indicating distress. Oxygen was administered, and R2 was transferred to the hospital. Interviews with staff revealed that the facility's system alerted CNAs of abnormal vital signs, which should have been reported to the nurse and then to the physician. However, there was no evidence that this protocol was followed, leading to a lack of timely intervention for R2's declining condition.
Failure to Follow Physician Orders for Bladder Scans and Catheterization
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was admitted with a diagnosis of urine retention. The orders required bladder scans every six hours and intermittent straight catheterization if the post-void residual was greater than 250 mL. However, the medical records revealed multiple instances where bladder scans were not completed as ordered, and catheterizations were performed without the necessary bladder scan results or when the results were below the threshold for catheterization. This inconsistency in following the physician's orders was confirmed by the Director of Nursing during an interview. The resident, who was cognitively intact, reported instances where nursing staff did not perform bladder scans before catheterization, contrary to the physician's orders. The Medication Administration Records further documented several occasions where the bladder scans were either not completed or the catheterization was performed despite the scan results being below the required threshold. These actions indicate a failure to provide appropriate care as per the physician's directives, leading to the deficiency noted in the report.
Failure to Notify Physician of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to notify the physician of urine culture results for a resident who was admitted with a diagnosis of urine retention. The resident, who was cognitively intact, had a urinalysis on 6/3/24, which showed a pending urine culture. On 6/4/24, a Nurse Practitioner noted the urinalysis was positive for leukocyte esterase and decided to await the culture results as the resident was asymptomatic. However, the urine culture results, which were positive for Klebsiella pneumoniae and Escherichia coli, were not obtained from the laboratory until 2/4/25. There was no documentation in the resident's medical record indicating that the physician was notified of these abnormal results or that the physician acknowledged them. The Director of Nursing confirmed that there was no evidence of physician notification or review of the urine culture results.
Failure to Document Urine Culture Results
Penalty
Summary
The facility failed to ensure that urine culture results were included in the medical record for a resident who was admitted with a diagnosis of urine retention. The resident, who was cognitively intact, had a urinalysis on 6/3/24 that indicated a pending urine culture. A Nurse Practitioner noted on 6/4/24 that the urinalysis was positive for leukocyte esterase and that they would await the culture results, as the resident was asymptomatic. However, the urine culture results, which were positive for Klebsiella pneumoniae and Escherichia coli, were not documented in the resident's medical record. The results were only obtained from the laboratory on 2/4/25 after being requested by the Nursing Home Administrator. The Director of Nursing reported that the culture results could not be located in the medical record and mentioned that physicians used a separate system for laboratory results.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. This deficiency was observed through multiple instances where dietary staff, including a dietary aide, a chef, and a registered dietitian, did not use a hand barrier to shut off the faucet after washing their hands. These observations were made on several occasions, indicating a pattern of non-compliance with the facility's hand hygiene policy and the U.S. Public Health Service 2017 Food Code, which requires the use of disposable paper towels or similar clean barriers to avoid recontaminating hands after washing. The facility's hand hygiene policy was reviewed and confirmed to be in place, outlining the proper procedure for handwashing. Despite this, staff members were observed not adhering to the policy, even though the dietary manager confirmed that training had been conducted and signs were posted at sinks. The failure to follow proper hand hygiene procedures potentially affected the facility's total census of 54 residents who receive meal services, increasing the risk of foodborne illness among the residents.
Insufficient Staffing and Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by multiple resident and family interviews. Resident #19 reported that despite communicating her preference to be up by 10:00 AM, she often had to wait until 11:00 AM or later for assistance. Additionally, she experienced delays in receiving help to use the bathroom, having to wait from 1:00 PM to 1:40 PM on one occasion. Resident #41 and her family member expressed concerns about longer call light response times, particularly on weekends. Resident #42, who required assistance with ambulation and toileting, was observed waiting for nearly an hour for help to use the bathroom, with staff unable to communicate effectively due to a language barrier. Resident #50 reported waiting up to an hour for call light responses and, on one occasion, had to yell for help because his call light was not within reach. He also experienced staff dismissing his calls for assistance. Resident #323, who primarily speaks Mandarin, expressed concerns about call light response times and had to approach the nurse's station for attention. During a test of her call light, staff were unable to communicate effectively with her due to the language barrier. Resident #167's family member reported having to take their loved one to the bathroom after the call light went unanswered for over 45 minutes. A CNA reported being assigned 16 residents, some on different hallways, and stated there was no system to alert them to call lights on other hallways. The most recent Resident Council minutes and a grievance form also reflected concerns about call light response times.
Environmental Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for its census of 56 residents and staff. During an environmental tour, an accumulation of dust and debris was observed on the flooring of the [NAME] Hall's dietary storage closet. Additionally, two physical therapy cold compresses were found stored in the activity room's freezer, which was designated for food storage only. Lift batteries and charging stations were also observed being stored in the soiled utility rooms on both the first and second floors. When inquired, the Housekeeping Supervisor indicated that the lift batteries and charging stations had always been stored there but agreed to move them to a cleaner area.
Failure to Maintain Resident Dignity and Communication
Penalty
Summary
The facility failed to maintain the dignity of two residents, resulting in feelings of anger, frustration, and potential decreased self-worth. Resident #42, who is cognitively intact and requires partial assistance for ambulation and toileting, was observed attempting to communicate with a staff member in a different language. The staff member, unable to understand, asked the resident to speak English and then left without providing the needed assistance, leaving the resident's call light turned off. This interaction occurred despite the resident's clear need for help with toileting, as indicated by her response and body language. Resident #50, who is cognitively impaired and requires assistance with personal care, reported concerns about the response time to his call light. He stated that he often had to wait up to an hour for assistance and that his call light was sometimes out of reach. On one occasion, after dinner, he had to yell for help because his call light was not accessible. Despite hearing staff members in the hallway, his calls for help were met with a dismissive response and laughter, making him feel frustrated and worthless. These incidents highlight the facility's failure to respect and uphold the residents' dignity and communication needs.
Failure to Timely Repair Power Wheelchair
Penalty
Summary
The facility failed to provide timely repair services for a power wheelchair for a resident, resulting in dissatisfaction and reduced independence. The resident, who was cognitively intact and had a history of difficulty walking, shortness of breath, repeated falls, and paralytic gait, reported that the powerpack of her wheelchair stopped working in the fall. Despite notifying the social worker months ago, no follow-up was conducted to repair the wheelchair. The resident expressed a desire to have the wheelchair repaired to regain her mobility and independence, especially for outdoor activities with her family. The deficiency was further highlighted by the lack of communication and follow-up among the facility staff. The Therapy Director, who started in March, was unaware of the resident's need for a new battery, and the Social Worker had only recently been informed of the issue. The Director of Nursing acknowledged the delay in addressing the repair needs and indicated that the previous Therapy Director had failed to inform the staff about the required repairs. This lack of timely action and communication led to the resident's prolonged dissatisfaction and reduced mobility.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in potential inaccuracies in care plans and unmet care needs. Resident 5, a female admitted to the facility, was documented in the MDS as having adequate hearing and not using a hearing aid. However, observations and interviews revealed that Resident 5 had profound hearing loss and routinely used hearing aids, which she had difficulty using correctly. The social worker was unaware of Resident 5's hearing loss and the use of hearing aids, indicating a significant oversight in the resident's assessment and care planning. Resident 22, a female with borderline personality disorder and bipolar disorder, was incorrectly coded in the MDS as not having a serious mental illness according to the state Level II Pre-Admission Screening and Annual Resident Review (PASARR) process. However, the clinical record included two annual Level II OBRA assessments that determined Resident 22 had a severe mental illness. The social worker acknowledged the incorrect coding, highlighting a failure to accurately document the resident's mental health status, which could impact the appropriateness of her care plan.
Failure to Implement Comprehensive Care Plans and Address Language Barriers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, resulting in unmet care needs and continued falls. The resident, who was cognitively intact but had multiple medical conditions including muscle weakness, orthostatic hypotension, and hemiplegia, required partial assistance for ambulation and toileting. Despite these needs, the care plan did not adequately address the resident's language barrier, which hindered effective communication and timely assistance. The resident primarily spoke Romanian, but the care plan incorrectly identified the language as Russian and failed to ensure the availability and use of translation services and communication tools. The resident experienced multiple falls, often while attempting to use the bathroom without assistance. Staff observations and interviews revealed that the resident's call light was frequently out of reach, and the resident was not consistently offered toileting every two hours as per the care plan. Additionally, interventions such as removing the bedside commode and encouraging the use of non-skid footwear were either not effectively implemented or failed to prevent further falls. The facility's documentation and post-fall evaluations did not adequately investigate the root causes of the falls, often attributing them to environmental factors or the resident's actions without addressing the underlying issues. Despite the resident's repeated falls and the family's expressed concerns about safety and care, the facility did not make necessary adjustments to the care plan or ensure consistent implementation of existing interventions. The lack of effective communication tools and translation services, combined with inadequate fall prevention measures, contributed to the resident's continued risk of falls and unmet care needs. Staff were often unsure about how to use translation services or locate communication tools, further exacerbating the resident's difficulties in receiving timely assistance.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure communication services were available and appropriately utilized for a resident who primarily spoke Romanian. The resident, who had multiple medical conditions including hemiplegia and chronic glaucoma, was observed struggling to communicate her need to use the bathroom. Staff members were either unaware of or did not use the available translation services, leading to delays in addressing the resident's needs. The resident was found in distress multiple times, including instances where she had fallen and was unable to describe the events due to the language barrier. The resident's care plan indicated the need for translation services and communication tools, but these were not effectively implemented. Observations revealed that the communication board was not readily accessible and staff were unsure how to use the translation services. This lack of proper communication tools and training led to the resident being unable to communicate her needs effectively, resulting in falls and delayed assistance. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed that the translation services were not consistently used. The resident's falls were documented, but the root cause was not adequately investigated due to the language barrier. The facility's failure to ensure effective communication contributed to the resident's repeated falls and unmet needs, highlighting a significant deficiency in care.
Failure to Ensure Appropriate Contracture Management
Penalty
Summary
The facility failed to ensure appropriate treatment and services for contracture management for a resident with multiple medical conditions, including chronic kidney disease, morbid obesity, and dementia. The resident, who had an amputation of the left leg above the knee and an acquired club foot, was observed lying in bed with her right foot in plantar flexion and her toes curled. She expressed that staff did not perform range of motion (ROM) exercises on her right foot and toes, which she wished they would do regularly. The medical record indicated a physician order for physical therapy evaluation and treatment, and the Point of Care (POC) documentation included tasks for daily maintenance of assisted active range of motion (AAROM) to all major joints. However, there was no documentation of completion or refusal of these tasks for the last 30 days. Interviews with staff revealed that the resident had refused ROM exercises in the past, leading the Certified Nursing Aide (CNA) to stop offering them. The Director of Nursing (DON) confirmed that ROM should be incorporated into daily care tasks and that staff are expected to perform ROM if indicated in the POC documentation. However, the DON could not explain the lack of documentation for the AAROM tasks and how staff should document refusals. This lack of documentation and follow-through on prescribed ROM exercises contributed to the deficiency in contracture management for the resident.
Failure to Prevent Falls and Address Communication Barriers
Penalty
Summary
The facility failed to prevent falls for a resident, resulting in recurrent falls and the potential for serious injury. The resident, who was admitted with multiple diagnoses including muscle weakness, orthostatic hypotension, and hemiplegia, experienced several falls despite having a care plan in place. The care plan included interventions such as encouraging the resident to wear non-skid footwear, ensuring the call light was within reach, and offering toileting every two hours. However, these interventions were not consistently followed or effective in preventing falls. On multiple occasions, the resident was found on the floor after attempting to use the bathroom without assistance. Staff observations and interviews revealed that the resident had a language barrier, speaking primarily Romanian, which hindered effective communication. Despite the availability of translation services and a communication board, these tools were not consistently utilized by the staff. The resident's call light was often found out of reach, and there were instances where the resident's requests for assistance were not promptly addressed. The facility's documentation showed repeated falls and post-fall evaluations, but the interventions implemented were either not new or not effective. For example, removing the bedside commode was listed as an intervention multiple times, and offering toileting every two hours was already an existing intervention. The facility's failure to address the root causes of the falls and ensure consistent use of communication tools contributed to the resident's recurrent falls and the potential for serious injury.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to ensure that pain medications were administered as ordered for two residents, resulting in increased pain and potential unmanaged pain. Resident #45, a cognitively intact female with severe chronic pain and multiple diagnoses including cancer and a hip fracture, reported frequent delays in receiving her scheduled Morphine Sulfate ER. Observations confirmed that her medication was administered late on multiple occasions, and there was no evidence that the physician had been notified of these delays. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and documented immediately, which was not done in this case. Resident #269, also cognitively intact, experienced severe pain and withdrawal symptoms due to delays in receiving her prescribed Fentanyl patch and Gabapentin. Despite the facility having these medications available in their pharmacy backup, the resident did not receive the Fentanyl patch until two days after it was due, and missed two doses of Gabapentin. Interviews with nursing staff revealed that the new admission process for residents with narcotic medications was not followed properly, and there was a lack of documentation explaining the delays. The Director of Nursing and other staff members acknowledged the deficiencies, stating that they would expect medications to be drop-shipped from the pharmacy within six hours and that any delays should be documented in the Electronic Medical Record. However, these expectations were not met, leading to unmanaged pain and withdrawal symptoms for the residents involved.
Failure to Ensure Proper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications for two residents, resulting in the potential for unauthorized access to medications, medication errors, and adverse reactions. Resident #7 was observed with two inhalers on her bed, which she reported she had been keeping in her top drawer for about a year. The inhalers were later found in the bottom drawer of the medication cart, and the Licensed Practical Nurse (LPN) on duty was unaware of their removal. The Director of Nursing (DON) confirmed that medications should be stored in a lockbox and that an assessment for self-administration should be conducted, which had not been done for Resident #7. Additionally, Resident #42 was observed with two inhalers and three eye drop bottles on her windowsill. The LPN present believed that Resident #42 had a self-administration assessment, but this was not confirmed. The DON was unaware of Resident #42's medications and reiterated the requirement for a lockbox and an assessment for self-administration, which had not been completed for Resident #42 either.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to justify the use of an antipsychotic medication for Resident #5 (R5). R5 was admitted with diagnoses including visual hallucinations, adjustment disorder with depressed mood, and dementia. Despite a history of gradual dose reductions (GDR) for Quetiapine, the facility did not document adequate indications for the medication's use, nor did they attempt further GDRs as recommended by psychiatric services. The medical record lacked documentation of the negative impact of R5's hallucinations, other causes and medications considered, and individualized nonpharmacological interventions in place. R5's Quetiapine dosage was reduced multiple times but was increased back to 50 mg at bedtime after the patient and her daughter expressed concerns. The facility's documentation did not include any mention of hallucinations during this period. Subsequent notes from the physician and social services indicated that R5 experienced delusions and hallucinations, but these were not consistently documented or tracked in the medical record. The facility also failed to document the impact of these symptoms on R5 or any nonpharmacological interventions that were in place. Interviews with staff, including an LPN, CNA, and social workers, revealed inconsistencies in the documentation and monitoring of R5's hallucinations and delusions. The Director of Nursing (DON) acknowledged that the documentation was unclear and incomplete. Despite recommendations from psychiatric services to attempt further GDRs, the facility did not follow through, and the medical record did not provide adequate justification for the continued use of Quetiapine at the prescribed dosage.
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 465 citations issued within 25 miles in the last 12 months — including the 2 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 Ann Arbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glacier Hills | 3.4 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Ann Arbor | 4.6 mi | ★★★★★ | 2 | 0 |
| Villa At Willow Place | 7.9 mi | ★★★★★ | 19 | 0 |
| The Gilbert Residence | 8 mi | ★★★★★ | 10 | 0 |
| The Villa At Parkridge | 8.5 mi | ★★★★★ | 16 | 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.