Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency Heights-detroit during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain an adequate supply of emergency food as outlined in its disaster menus. Key non-perishable items such as assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes were missing and could not be substituted with other foods on hand. Additional items listed on the disaster menus were also not available, though some could potentially be substituted in an emergency. Facility leadership acknowledged the deficiency during interviews.
Surveyors identified failures in food safety and sanitation, including improper cooling and storage of cooked foods, missing caulking at a handwashing sink, unsanitary handling and storage of an ice scoop, and lack of proper labeling for food in a resident refrigerator. Staff were unaware of correct procedures, and facility policy for labeling and checking food was not followed.
Surveyors found that the facility's walk-in freezer was not consistently maintaining proper temperatures, with repeated observations of soft ice cream and a door that did not seal correctly, allowing cold air to escape. The Dietary Manager and NHA were aware of the issue but had not taken steps to address it prior to the survey, resulting in a deficiency related to equipment maintenance and food safety standards.
Two residents were found using wheelchairs with damaged and frayed armrests, missing padding, and exposed foam, resulting in discomfort and surfaces that could not be properly cleaned. Staff confirmed that the wheelchairs should have been repaired or replaced, and that the condition should have been reported by nursing.
Two residents did not receive their full prescribed medications when an LPN prepared and stacked medication cups for multiple residents at once, omitting some medications and not following the facility's policy for safe medication administration. Both the nurse manager and DON confirmed this practice was not in line with professional standards.
A dependent resident with severe cognitive impairment and multiple health conditions was repeatedly observed with excessively long and discolored fingernails, despite documentation indicating daily ADL care including nail care. Staff confirmed the need for nail trimming and cleaning, and facility policy required such grooming for residents needing extensive assistance, but the care was not provided as required.
A resident with chronic kidney disease and epilepsy did not receive a physician-ordered Keppra blood level lab draw due to an incorrectly entered order by a nurse. The lab test was not completed, and there was no documentation or notification to the physician regarding the missed test, despite facility policy requiring adherence to physician orders.
A resident with a history of myocardial infarction and intact cognition had a signed DNR order and corresponding physician notes, but the EMR information page incorrectly listed the resident as Full Code after a hospital readmission. Nursing staff and the DON confirmed that care decisions are based on the EMR code status, and the error was due to an incorrect update, resulting in the resident's wishes not being accurately reflected in the record.
A resident with severe cognitive impairment was diagnosed with pneumonia, and an antibiotic was prescribed, but the Resident Representative was not notified of this significant change in health status. The facility's policy requires such notifications, but it was not followed in this case.
A resident with severe cognitive impairment developed an unstageable pressure ulcer due to the facility's failure to implement necessary interventions such as a specialty mattress and regular repositioning. Despite being identified as at moderate risk, the resident was often observed without appropriate pressure-relieving devices, and staff showed a lack of knowledge regarding the use of these devices.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination of food. Observations revealed staff handling food without gloves, not performing hand hygiene after glove removal, and not following proper food handling techniques, despite existing policies emphasizing these practices.
The facility failed to notify a resident's family of a change in condition and subsequent hospital transfer. The resident's room was found empty, and family members were unaware of the transfer until they inquired at the nurse's station. A review of the EHR confirmed no documentation of family notification, and the DON acknowledged the lapse in following the facility's 'Transfer and Discharge' policy.
The facility failed to address residents' concerns about call light response times, leading to dissatisfaction and unmet needs among 13 out of 20 residents. Despite the concerns being raised in a resident council meeting, the issue was not documented or communicated to the appropriate staff, and the Administrator was unaware of the problem.
The facility failed to ensure accurate transfer information was communicated to the receiving hospital for a resident. The resident's EHR indicated a transfer due to abnormal labs, but the 'Transfer Form' inaccurately documented 'shortness of breath' based on outdated information. Both the NP and DON confirmed the inaccuracy, and the responsible nurse had copied information from a previous form.
The facility failed to apply splinting devices for two residents, leading to potential increased joint contracture and pain. One resident with severe cognitive impairment and hemiplegia was observed without a hand roll, and another resident with contractures and severe cognitive impairment was observed without elbow braces. The LPN admitted to not applying the splints despite documenting otherwise, and the DON confirmed the lack of a restorative nurse or aide.
The facility failed to date a respiratory water bag for a resident with a tracheostomy, leading to a deficiency in providing safe and appropriate respiratory care. The resident, who has chronic respiratory failure and severe cognitive impairment, had a water bag for oxygen humidification observed multiple times without a date label. Interviews with an LPN and the DON confirmed the requirement for dating the water bag.
The facility failed to maintain accurate documentation in the EHR and MAR for three residents, leading to incomplete medical records and inadequate care delivery. An LPN admitted to not applying prescribed braces and hand rolls despite documenting otherwise, and a transfer form inaccurately stated the reason for a resident's hospital transfer.
The facility failed to ensure that two residents were provided with influenza vaccination and education, resulting in the potential for the development and spread of influenza. The Infection Preventionist reported that these residents did not have documentation of a current influenza immunization or refusal. The DON confirmed that both residents should have been educated and offered the influenza vaccine, as per the facility's policy.
A resident receiving palliative care was found expired on the floor with an injury to the back of her head. The facility failed to document an Accident and Incident (A&I) report or conduct a thorough investigation as required by its policy. The Safety Coordinator and DON acknowledged the lack of documentation and investigation, leading to a deficiency in compliance with state regulations.
Inadequate Emergency Food Supply
Penalty
Summary
The facility failed to ensure an adequate supply of emergency food was available, as required by their emergency planning recommendations. During an observation and interview with the Dietary Manager, it was found that the facility's disaster menus for three days included specific non-perishable items such as assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes, which were not present in the facility's emergency food supply and could not be substituted with other foods on hand. Additional items listed on the disaster menus, including green beans, chicken and dumplings, carrots, apricots, ham, green peas, pulled chicken, mixed vegetables, assorted sodas, and stewed tomatoes, were also missing but could potentially be substituted in an emergency. The Nursing Home Administrator confirmed that the facility should have the correct amount of food for three days, acknowledging the deficiency when interviewed. No additional documentation or information was provided by facility leadership during the exit conference.
Deficiencies in Food Safety, Sanitation, and Labeling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in food safety and sanitation practices within the facility. Cooked, potentially hazardous foods such as meatballs, corned beef, baked beans, and diced potatoes were stored in the walk-in cooler without completion of required cooling logs, and staff responsible for storing these foods were unaware of proper cooling procedures. Additionally, the caulking around the handwashing sink was missing, which the Dietary Manager acknowledged could allow bacteria to grow if water seeped behind the sink. An ice scoop was observed being placed directly back into the ice chest after use, rather than being stored in a designated bin, raising concerns about cross-contamination. The staff member handling the ice scoop was not wearing gloves and admitted the scoop should have been stored outside the ice chest. Further inspection of a resident refrigerator on the first floor revealed several food items, including partially eaten stir fry, a carbonated beverage, bread, sliced salami, sliced cheese, and salad, that were not labeled with resident names or dates. Facility policy requires all food brought in to be checked, sealed, labeled with content, resident name, date received, and an expiration date, but these procedures were not followed. These findings were confirmed through interviews with the Dietary Manager and review of facility policy and the FDA Food Code.
Failure to Maintain Walk-In Freezer in Proper Working Order
Penalty
Summary
Surveyors observed that the facility failed to maintain the walk-in freezer in proper working order, as evidenced by repeated findings of an internal temperature of 9°F and soft, not fully frozen, ice cream during multiple visits. The freezer door did not seal properly, with a visible gap allowing cold air to escape. The Dietary Manager acknowledged awareness of the door issue but did not consider it a concern since meat remained frozen, and stated that a new freezer was needed. The Nursing Home Administrator confirmed knowledge of the faulty freezer door but had not initiated replacement prior to the survey. These findings were supported by reference to the 2013 FDA Food Code, which requires frozen foods to be maintained in a frozen state and equipment to be kept in proper repair.
Failure to Maintain Safe and Clean Wheelchairs for Two Residents
Penalty
Summary
The facility failed to maintain the wheelchairs of two residents in a safe and comfortable condition. Observations revealed that one resident's wheelchair had both armrests in disrepair, with one armrest severely frayed and only partially covered, and the other missing padding entirely, exposing bare metal. The back section of the same wheelchair was also partially missing its covering, exposing the foam underneath. Another resident's wheelchair had both armrests split and frayed, with exposed padding, and the resident reported that the armrests sometimes caused discomfort. Interviews with facility staff confirmed that managers were responsible for identifying wheelchair repairs and contacting maintenance, and that replacement pads were available. The Therapy Manager and DON both acknowledged that the damaged armrests and back support should have been replaced, noting that the cracked surfaces could not be adequately cleaned and could cause skin issues. Clinical records indicated that both residents used wheelchairs for mobility and had diagnoses that included mobility impairments. The DON stated that the condition of the wheelchairs should have been reported and addressed by nursing staff.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice for two residents. An LPN was observed preparing medication cups for two different residents at the same time, stacking the cups on the medication cart, and only including packaged medications while omitting floor stock medications. The LPN stated that this was done to save time and acknowledged that it did not align with the facility's medication administration policy. Upon inspection, it was found that neither resident had all of their prescribed 9:00 AM medications in their respective cups, with several medications missing for both residents. Interviews with the nurse manager and the DON confirmed that the facility's policy requires preparing and administering medications for one resident at a time, immediately prior to administration, and then signing them out. Both staff members expressed that the observed practice was unsafe and not in accordance with professional standards or facility policy. The facility's policy, last revised in October 2023, specifically states that medications are to be administered in an accurate, safe, timely, and sanitary manner, and that safe preparation practices must be followed.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident, who required maximum assistance for activities of daily living (ADLs) due to severe cognitive impairment and diagnoses including dementia and protein-calorie malnutrition, was observed on multiple occasions to have excessively long and discolored fingernails. The resident's nails extended one fourth to one third of an inch beyond the fingertips and appeared light brownish in color. Despite being non-responsive to interview questions, the resident's condition was confirmed by both a certified nurse assistant (CNA) and a unit nurse manager/licensed practical nurse (LPN), who acknowledged that the nails needed to be trimmed and cleaned. A review of the resident's electronic medical record (EMR) indicated that daily ADL care, including nail care, was documented as provided over the past thirty days, with no significant behavioral resistance noted. The facility's policy required grooming tasks such as nail trimming for residents needing extensive assistance. However, the observed state of the resident's nails and staff interviews revealed that appropriate nail care was not performed as required, despite documentation suggesting otherwise.
Failure to Complete Physician-Ordered Keppra Level Lab Draw
Penalty
Summary
A physician ordered a Keppra (levetiracetam) blood level to be drawn for a resident with chronic kidney disease and epilepsy who had been readmitted to the facility. Review of the resident's electronic health record (EHR) showed that the Keppra level was ordered but not completed, and there were no progress notes indicating that the blood draw had occurred. The resident had no documented seizure activity during this period. The Director of Nursing (DON) confirmed upon review that the Keppra level had not been drawn, attributing the failure to an incorrectly entered order by a nurse. The facility did not have a specific policy for lab or blood draws, but did have a policy for following physician's orders, which was not adhered to in this case. As a result, the physician was unaware that the ordered lab test had not been completed.
Failure to Accurately Document Resident Code Status in EMR
Penalty
Summary
The facility failed to accurately document a resident's code status in the electronic medical record (EMR), resulting in a discrepancy between the resident's documented wishes and the information available to staff. The resident, who had a history of myocardial infarction and demonstrated intact cognition, had a signed Do-Not-Resuscitate (DNR) order on file, which was also reflected in multiple physician progress notes. However, the EMR information page incorrectly listed the resident as Full Code following a hospital readmission, due to an error made during the update of the resident's status. Interviews with nursing staff, including LPNs and the Unit Manager, confirmed that staff rely on the EMR information page to determine code status in emergency situations. The Director of Nursing also acknowledged that the EMR was marked inaccurately and that the resident should have remained a DNR according to their wishes. The facility's policy recognizes the right of residents to self-determination and to have advance directives respected, but this was not upheld in this instance due to the documentation error.
Failure to Notify Resident Representative of Pneumonia Diagnosis
Penalty
Summary
The facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and a physician's order for an antibiotic for a resident. The resident, who had severe cognitive impairment and was diagnosed with Alzheimer's disease, dysphagia, and adult failure to thrive, experienced a change in condition on January 15, 2025. The resident was noted to feel hot to the touch, and a physician recommended a chest x-ray. The RR was notified of this initial change. However, later that day, after the chest x-ray results indicated pneumonia and an order for Doxycycline was made, the RR was not informed of the new diagnosis and treatment plan. During an interview, the Director of Nursing (DON) acknowledged awareness of the pneumonia diagnosis and the antibiotic prescription but admitted that the RR had not been notified. The facility's policy on Notification of Change requires informing the resident, consulting with the resident's practitioner, and notifying the RR of significant changes in the resident's health status. This policy was not followed in this instance, as the RR was not informed of the significant change in the resident's health status and the new treatment plan.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers for a resident, resulting in the development of an unstageable pressure ulcer on the resident's left hip. The resident, who had severe cognitive impairment and required substantial assistance to move, was observed multiple times without appropriate pressure-relieving devices such as a specialty mattress or foam wedges. Despite being identified as at moderate risk for pressure ulcers, the resident was often seen in a wheelchair or on a standard mattress without the necessary support to prevent skin breakdown. The resident's electronic health record indicated no open skin areas upon admission, but a dark circle on the left hip was noted later, which progressed to an unstageable pressure ulcer. The care plan for the resident included the use of a pressure reduction mattress and regular turning and repositioning, but these interventions were not consistently implemented. Observations revealed that the resident's mattress was a standard one, and there were no positioning devices in the room, even after the pressure ulcer was identified. Interviews with staff, including the RN, LPN, and DON, highlighted a lack of knowledge and communication regarding the ordering and use of specialty mattresses. The DON eventually replaced the standard mattress with an LTC 105 mattress, suitable for stage 3 or 4 pressure ulcers, but this was done hours after the deficiency was noted. The facility's skin management policy and mattress grid were not followed, leading to the resident's condition worsening.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to an increased potential for cross-contamination of food and foodborne illness. During an observation, Dietary Cook B was seen touching a piece of cooked pork loin with bare hands while checking its temperature and then placing it back in the pan without wearing gloves. Additionally, Assistant Cook C removed gloves and did not perform hand hygiene before writing down temperatures in a book. Dietary Cook B was also observed removing gloves, touching serving utensils, and searching for buns without performing hand hygiene. Similarly, Dietary Aide E removed gloves, entered the walk-in cooler, and exited with ranch in hand without washing hands, prompting CDM D to instruct her to wash her hands. The Certified Dietary Manager (CDM) D confirmed that staff should wash their hands after removing gloves and change gloves between tasks. The facility's policies, including the U.S. Public Health Service 2017 Food Code and the facility's own Food Handling and Production policy, emphasize the importance of hand hygiene and using proper food handling techniques to prevent foodborne illness. Despite these policies, the staff's actions did not align with the required standards, leading to the observed deficiencies in maintaining sanitary conditions in the kitchen.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the family of a resident's change in condition and subsequent transfer to the hospital. On the morning of 04/04/24, it was observed that the resident's room was empty, and an LPN confirmed that the resident had been sent to the hospital before her shift started. Later that morning, a family member arrived at the nurse's station inquiring about the resident's whereabouts and was informed by another LPN that the resident had been transferred to the hospital. The family member expressed frustration, stating that they had not been notified and that this had happened multiple times before. A phone call to another family member confirmed that they were also unaware of the transfer. A review of the resident's Electronic Health Record (EHR) showed no progress notes or documentation indicating that the family had been notified of the change in condition or transfer to the hospital. The Nurse Practitioner who ordered the transfer due to abnormal lab results requiring hospital treatment confirmed that there were no progress notes in the EHR and could not verify if the family had been notified. The Director of Nursing (DON) also reviewed the EHR and confirmed the lack of documentation regarding the transfer and family notification. According to the facility's 'Transfer and Discharge' policy, notice of an emergency transfer should be provided to the resident and their representative as soon as practicable, which was not adhered to in this case.
Failure to Address Call Light Response Time Concerns
Penalty
Summary
The facility failed to respond to residents' concerns about staff call light response times, leading to dissatisfaction and unmet needs among 13 out of 20 residents. During a resident council meeting, multiple residents expressed their dissatisfaction with the call light response times, with one resident mentioning a wait time of three and a half hours. Despite these concerns being raised, the facility did not take appropriate action to address them, as evidenced by the lack of documentation in the pink forms used for tracking such issues. The Activities Director indicated that the process for addressing resident council concerns involves filling out a pink form and following up with a department manager. However, none of the forms reviewed addressed the issue of call light response times, and the concerns mentioned in the resident council meeting had not been communicated. Additionally, the Administrator was unaware of the residents' concerns about call light response times, indicating a breakdown in communication and follow-up within the facility's grievance process.
Failure to Communicate Accurate Transfer Information
Penalty
Summary
The facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one resident reviewed for discharges and transfers. On the morning of 04/04/24, a Licensed Practical Nurse (LPN) reported that the resident was sent to the hospital before her shift started and she was unaware of the circumstances requiring the transfer. The resident's Electronic Health Record (EHR) indicated an order for transfer due to abnormal labs, but the 'Transfer Form' inaccurately documented the reason as 'shortness of breath' based on outdated information from a previous transfer form dated 3/12/24. There was no corresponding progress note to provide additional medical information to the receiving hospital. Upon review, the Nurse Practitioner (NP) confirmed that the 'Transfer Form' was inaccurate and that the resident did not have shortness of breath. The NP was in the process of documenting a progress note at the time of the review. The Director of Nursing (DON) also confirmed the inaccuracy of the 'Transfer Form' and noted that the nurse responsible had copied information from a previous form without explanation. The facility's 'Transfer and Discharge' policy requires a transfer form, a list of medications, and a copy of care plan goals to be sent to the receiving hospital, along with documentation of the hospital transfer in the medical record, which was not followed in this instance.
Failure to Apply Splinting Devices
Penalty
Summary
The facility failed to apply splinting devices for two residents, resulting in the potential for increased joint contracture, loss of range of motion, and increased pain. One resident was observed multiple times with a clenched left hand and no hand roll or towel roll in place, despite the Electronic Health Record (EHR) and Medication Administration Record (MAR) indicating that a hand roll should be applied during the day. This resident had diagnoses including Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis on the left side, with severe cognitive impairment and dependency for activities of daily living (ADLs). Another resident was observed multiple times with bent elbows and elbow braces not worn, despite the EHR and MAR indicating that elbow braces should be applied daily. This resident had diagnoses including chronic respiratory failure, contractures to both elbows, and traumatic brain injury, with severe cognitive impairment and dependency for ADLs. The Licensed Practical Nurse (LPN) admitted to not applying the splints but documenting that they were applied. The Director of Nursing (DON) confirmed that there was no restorative nurse or aide, and that floor staff were responsible for applying the splints, which were not applied as ordered by the physician.
Failure to Date Respiratory Water Bag
Penalty
Summary
The facility failed to date a respiratory water bag for a resident with a tracheostomy, leading to a deficiency in providing safe and appropriate respiratory care. On multiple occasions, the resident's water bag for tracheostomy oxygen humidification was observed without a date label. Interviews with an LPN and the Director of Nursing confirmed that the water bag should be dated to ensure proper monitoring and replacement. The resident, who has chronic respiratory failure, a tracheostomy, contractures in both elbows, and a traumatic brain injury, was admitted to the facility with severe cognitive impairment. The manufacturer's guidelines for the water bag recommend replacing it every 60 days or earlier if it becomes discolored.
Inaccurate Documentation in EHR and MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Electronic Health Record (EHR) for three residents, resulting in inaccurate and incomplete medical records and inadequate care delivery. For one resident, the Medication Administration Record (MAR) inaccurately documented the application of elbow braces, which the Licensed Practical Nurse (LPN) admitted to not applying. Similarly, another resident's MAR inaccurately documented the application of a hand roll, which the same LPN also admitted to not applying. The Director of Nursing (DON) confirmed that the documentation was incorrect and incomplete, which could affect the residents' care and treatments. Another resident was transferred to the hospital for abnormal labs, but the transfer form inaccurately documented the reason for the transfer as shortness of breath, which was not the case. The Nurse Practitioner (NP) confirmed the inaccuracy and noted the absence of a corresponding progress note to provide accurate medical information to the receiving hospital. The DON confirmed that the transfer form was inaccurate and that the nurse had copied information from a previous transfer form without proper verification.
Failure to Provide Influenza Vaccination and Education
Penalty
Summary
The facility failed to ensure that two residents, R126 and R87, were provided with influenza vaccination and education, resulting in the potential for the development and spread of influenza among vulnerable residents. On 4/5/2024 at 11:00 AM, the Infection Preventionist (IP) reported that these residents did not have documentation of a current influenza immunization or refusal. R126, admitted with diagnoses of respiratory failure and heart failure, and R87, admitted with diagnoses of urinary tract infection and dementia, both lacked documentation indicating that the influenza vaccine was offered or contraindicated. The Director of Nursing (DON) confirmed that both residents should have been educated and offered the influenza vaccine. The facility's policy, revised on 1/11/22, mandates that residents be offered immunization against influenza annually, with the program running from early October through March 31st, and every admission screened and given the vaccine if indicated after receiving education regarding the vaccine.
Failure to Investigate Injury and Death
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and unexpected death of a resident receiving palliative care. The resident was found expired on the floor with an injury to the back of her head. There was no Accident and Incident (A&I) report or total body assessment documented in the resident's Electronic Health Record (EHR). The Safety Coordinator and the Director of Nursing (DON) acknowledged the lack of documentation and investigation, despite the facility's policy requiring thorough investigation and documentation of such incidents. The DON admitted to starting an investigation but did not document it until later, which was not in compliance with the facility's Abuse Prohibition Policy. The facility's policy mandates that allegations of abuse, neglect, or adverse events be thoroughly investigated and documented. However, in this case, the facility did not follow its policy, as there was no immediate documentation or investigation into the resident's death and injury. The DON and the Safety Coordinator could not confirm if the resident had an injury to the back of her head, highlighting the lack of a proper investigation. This failure to document and investigate the incident led to a deficiency in the facility's compliance with its own policies and state regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Great Lakes Crossing | 0 mi | ★★★★★ | 8 | 0 |
| West Oaks Senior Care & Rehab Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Beaconshire Nursing Centre | 1.7 mi | ★★★★★ | 4 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 23 | 0 |
| Oakland Nursing Center | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.