Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Lack of Documented Daily RN Coverage: Surveyors found that the facility did not have documented RN coverage scheduled for at least 8 consecutive hours per day, 7 days a week. Review of staffing postings showed multiple days without the required RN coverage, and the ANHA stated there were no other documents available to verify RN coverage. No policy was provided by the end of the survey.
Food service sanitation and equipment maintenance deficiencies were observed in the kitchen and related areas. The dish machine was operating with no chlorine detected, the DS stated she did not know how to prime the pump, the dumbwaiter lift had accumulated debris and dirt, two equipment storage units had rust-covered shelves lined with foil, and the ice machine drip panel was soiled with a black mold-like substance.
Improper garbage disposal and failure to maintain the dumpster area were observed when the outdoor garbage enclosure was found with the side door open, squirrels exiting the dumpster, and debris scattered throughout the area, including used gloves, food packaging, and bags of garbage. A collapsing shed at the back of the enclosure was also full of debris, and the RMD and maintenance staff acknowledged the need for removal and clean up.
Dirty Bathroom, Room Clutter, and Missing Backflow Protection: A resident room had a faded, worn mattress and clothing stored in bags and a laundry basket on the floor. A community bathroom used by residents was observed dirty with toilet paper, urine, damp paper towels, and later a brownish dirt-like substance on the floor; the HS said the bathroom had probably not yet been cleaned and there was no housekeeping log. A main floor utility sink in the janitor closet was also observed connected directly to the chemical dispensing system without a required backflow protection device at the faucet.
Insufficient Towels and Laundry Supply: The facility failed to maintain an adequate supply of towels for residents. A CNA reported towels had run short off and on, the linen closet was empty, and extra towels were later found stored in an office. The HS stated both washers were offline and laundry was being sent to a sister facility, while the ADN confirmed the washers were not operating and expected all residents to have towels as needed.
A facility failed to give an ABN and NOMNC at least 48 hours before Medicare coverage ended for one resident. The resident signed the forms only one day before therapy ended, and the Business Office Staff confirmed the forms were delivered after the notice period they understood was required. The resident had osteomyelitis of the L ankle and foot, and the MDS noted intact cognition.
The facility failed to develop complete care plans for three residents with identified needs and behaviors. One resident with severe cognitive impairment and restorative therapy orders had no restorative care plan or treatment records, another cognitively intact resident who refused medications for months had no care plan addressing refusal of care, and a third resident identified as a smoker was observed smoking but had no smoking-related care plan in the chart.
Failure to provide and document restorative ROM services affected two residents with stroke-related impairments. One resident with severe cognitive impairment and hemiplegia was referred to restorative therapy but had no documented treatments and was not on the restorative caseload. Another resident with right-side paralysis had therapy recommendations for ROM and muscle strength maintenance, but the EMR had no restorative notes or active care plan interventions, and the restorative aide reported staffing shortages and lack of documentation.
Medication storage and labeling were not maintained as required. In a high med cart, vitamin D was found with an expiration date of 05/2025 and glucose strips were not dated when opened. In a low med cart, an umeclidinium dry powder inhaler was not dated when opened, and in the med room refrigerator an opened tuberculin vial was found expired. The med room door was also observed unlatched and able to open without a key, and an LPN stated it was supposed to be closed.
Surveyors identified that multiple residents with complex medical conditions and on multiple daily medications, including psychotropics and antipsychotics, did not have required monthly medication regimen reviews (MRRs) documented by a pharmacist for at least 12 months. Despite requests, staff were unable to provide or locate the missing MRRs in the electronic medical record, indicating a failure to follow facility policy and regulatory requirements.
Surveyors found that food items brought in from outside for residents were not dated and the resident refrigerator's temperature was not consistently monitored. The refrigerator lacked a visible thermometer, the temperature log was outdated, and several food containers were undated, contrary to facility policy.
A strong and persistent urine odor was observed throughout the facility, including entryways and hallways, over multiple days. The carpets, which covered all hallways, had no documented cleaning schedule or recent cleaning records, and staff were unable to provide a policy for carpet maintenance or ensuring a home-like environment. This resulted in a failure to maintain a clean and comfortable setting for all residents, staff, and visitors.
The facility lacked a site-specific Water Management Plan, with missing risk assessments, system diagrams, and monitoring for Legionella, and staff were unfamiliar with the program. Additionally, an LPN failed to use required PPE during a high-contact activity for a resident on Enhanced Barrier Precautions, and staff interviews revealed uncertainty about PPE requirements.
The facility did not ensure eight hours of RN coverage within a 24-hour period on multiple days, with gaps in coverage documented over several months. The DON/NHA and a Unit Manager RN shared responsibility for staffing, but frequent call-ins and staffing instability contributed to the deficiency. Documentation of staffing policies and RN coverage was not provided during the survey.
Two multi-use ophthalmic medications for single resident use were found opened in a medication cart without being labeled with the date they were opened. An LPN, the unit manager, and the DON all confirmed that such medications should be dated when opened, but this was not done. The facility was also unable to provide a policy on medication storage and labeling when requested.
A resident with dementia and impaired cognition, known to be at risk for elopement, exited the facility unsupervised through a dining room door with a malfunctioning alarm. Staff only became aware of the resident's absence after being alerted by a neighbor, and the resident was found walking down the street. The door was last checked several days prior, and maintenance was unaware of the alarm issue. Supervision was interrupted during shift change, and the exit area was only partially secured.
The facility failed to maintain a homelike environment in resident showers and ensure backflow protection for the ice machine. Observations showed black mold in the ice machine drain and shower rooms, along with lime build-up on a sink faucet. The Nursing Home Administrator acknowledged these issues.
A resident was transported from a medical appointment in a manner that violated their rights to dignity and safety. The facility's van was late, and the driver had two children without car seats, who hit the resident during the ride. The driver also exhibited inappropriate behavior by cursing at the children and a doctor's office manager. The Nursing Home Administrator was informed but did not follow up with the resident or their family.
A facility failed to consistently apply a wound vac for a resident with a history of osteomyelitis and pressure ulcers. After a doctor's appointment, the resident returned without the wound vac because the facility did not send the necessary supplies. The wound vac was found with dried blood and was not reapplied as per physician orders. The MAR showed multiple instances of non-application, and the facility's policy on wound treatment was not followed.
The facility failed to document showers for two dependent residents, leading to incomplete medical records. One resident, with conditions requiring extensive assistance, had only three shower records over 60 days, with two refusals. Another resident, needing assistance due to a brain injury, had no shower documentation. The Nursing Home Administrator acknowledged the documentation gap.
The facility failed to provide evidence of a comprehensive infection prevention and control program, affecting all 32 residents. The NHA reported that the DON, who was on vacation, had the necessary documentation. The Infection Control Program book lacked documentation of comprehensive surveillance and data analysis, despite the facility's policy requiring oversight by an Infection Preventionist.
The facility failed to ensure that the QAPI committee met quarterly and included required members, affecting all 33 residents. Several meetings were missing, and those that occurred lacked key members such as the NHA and DON. The current NHA, who started in May 2024, could not explain the deficiencies.
The facility failed to implement enhanced barrier precautions for two residents with indwelling urinary catheters and skin impairments, and lacked proper infection control surveillance documentation. Additionally, the facility did not have an active water management plan to reduce the risk of Legionella and other pathogens.
The facility failed to conduct regular care conferences for four residents, leading to a deficiency in the development and implementation of person-centered care plans. Residents with various diagnoses, including high blood pressure, stroke, schizoaffective disorder, and dementia, had missing or delayed care conferences, contrary to the facility's policy.
The facility failed to follow up and document physician notification of pharmacy recommendations for four residents. Despite identified pharmacy concerns, actual reports were not received, and it could not be determined if the concerns were addressed. The DON and NHA acknowledged the expectation for timely completion and follow-up of pharmacy reviews.
The facility failed to maintain effective contact with a resident's representative, despite multiple attempts by staff over several months. The resident, with significant medical conditions, experienced multiple hospitalizations, and the legal guardian was suspended without new representation being obtained.
The facility failed to develop an elopement baseline care plan for a resident with severe cognitive impairment and a high risk of elopement. Despite being assessed as at risk, the resident's care plan lacked necessary goals and interventions, leading to an incident where the resident exited the building and was found outside, although unharmed. Interviews with staff confirmed that baseline care plans should be completed within 48 hours of admission, but this was not done in this case.
A facility failed to implement care plan interventions for a resident on psychotropic medication. Despite the resident's diagnoses and moderate cognitive impairment, there was no care plan addressing psychiatric behaviors or behavior related to the medications. The DON confirmed that alternative measures should be tried and documented before administering medication, but this was not done.
A resident with Alzheimer's Disease, Heart Disease, and Hypertension was transferred to another facility without a discharge summary or recapitulation of stay. The Nursing Home Administrator confirmed the absence of the required documentation, which is mandated by the facility's Discharge Planning Process policy.
The facility failed to follow a hospital recommendation, a physician's order, and follow up on a dental consultation for two residents. One resident did not receive a recommended MRI and neurology follow-up, while another did not receive a referral for necessary dental extractions.
A resident with severe cognitive impairment and multiple medical conditions experienced 12 falls over several months due to the facility's failure to supervise and assess the effectiveness of fall prevention interventions. Despite having a care plan in place, the interventions were not revised following each fall, nor was their effectiveness documented, leading to repeated falls and hospital transfers.
The facility failed to maintain orders for indwelling catheter care for a resident with multiple medical conditions, including dementia and obstructive uropathy. Despite observations of the resident with an intact catheter, orders for catheter care and changes were discontinued and not renewed, as confirmed by the DON.
The facility failed to ensure that PRN psychotropic medications had adequate indications for use and a stop date for a resident with multiple diagnoses, including Schizophrenia and Diabetes Type 2. The DON and two LPNs confirmed that orders for antipsychotic medications should include a reason and a stop date, but this was not done.
The facility failed to control urine odors and ensure adequate ventilation, as observed by surveyors. A strong urine odor was noted in specific rooms and common areas, and the bathroom vent in one room was found to be ineffective. Despite efforts to clean, the odor persisted, and the facility's policy on maintaining a safe and homelike environment was not effectively implemented.
The facility failed to maintain safe and sanitary kitchen conditions, with issues such as rusted cans, frost build-up in freezers, a malfunctioning refrigerator, and general uncleanliness. The dietary manager acknowledged the problems but did not take immediate corrective action, and the DON confirmed that the facility did not adhere to its own food safety policies.
The facility failed to ensure a clean and safe environment, affecting all residents. Multiple rooms had various cleanliness and maintenance issues, and one resident's tube feeding equipment was significantly soiled. The DON acknowledged these deficiencies.
The facility failed to ensure handrails were firmly mounted in the upper hallway, affecting five residents. Several handrails were observed to be loose and easily jiggled when pressure was applied. These concerns were acknowledged by the maintenance supervisor and reviewed with the DON, who confirmed the need for a safe environment. A policy related to handrail maintenance was requested but not received before the survey exit.
Lack of Documented Daily RN Coverage
Penalty
Summary
The facility failed to have documented RN coverage scheduled for at least eight consecutive hours per day, seven days a week. During the Staffing Task of the survey, surveyors requested six months of Daily Staffing Census/Postings, and the postings provided showed multiple dates without eight consecutive hours of RN coverage, including 3/5, 3/6, 3/7, 3/8, 3/28, 3/29, 3/31, 4/14, 4/21, 4/24, and 4/28/2026. On 5/21/2026 at 3:12 PM, the Acting Nursing Home Administrator stated there were no other documents available to review for RN coverage. The facility did not provide a policy addressing the concern by the end of the survey.
Food Service Area Sanitation and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. On a tour of the basement level kitchen with the dietary supervisor, the low temperature dish machine was operating with no chlorine detected by a test strip. The dietary supervisor stated the chlorine supply had just been changed but no chlorine was being dispensed and said she was unsure how to prime the pump. She also stated she would follow up with a service technician by phone. The dietary supervisor set up and tested quaternary sanitizer in the 3-compartment sink and indicated it would be used as the sanitize step for all cleaned equipment until the automatic dish machine was properly dispensing sanitizer. Additional observations showed the dumbwaiter lift used to convey food carts between floors was soiled with an accumulation of debris and dirt build up, and the dietary supervisor stated she was aware it needed more frequent cleaning. Two clean equipment storage units were observed with shelves covered in aluminum foil because there was rust build up on the surfaces and they were no longer easily cleanable. In the main level hydration/supply room, the ice machine was observed with the water drip panel soiled with an accumulation of a black mold-like substance. A facility policy regarding kitchen/dietary equipment maintenance was requested but not provided for review by survey exit.
Improper Garbage Disposal and Unclean Dumpster Area
Penalty
Summary
Improper disposal of garbage and failure to maintain the dumpster area were observed during survey. The outdoor garbage enclosure was found with the side door open, squirrels exiting the dumpster on approach, and debris scattered throughout the enclosure, including used gloves, food packaging, and bags of garbage. A collapsing shed at the back side of the garbage enclosure was also full of debris. When questioned, the regional maintenance director and regional maintenance staff member acknowledged the debris and the need for removal and clean up, and the regional maintenance director stated the damaged shed was planned for demolition and removal. A facility policy regarding garbage removal was requested but was not provided for review by survey exit.
Dirty Bathroom, Room Clutter, and Missing Backflow Protection
Penalty
Summary
The facility failed to maintain cleanliness in a resident bathroom and in a resident room, and failed to ensure appropriate backflow prevention was installed at a plumbing fixture. On 05/20/26 at 9:17 AM, the sleeping area of the mattress for bed D in a room was observed faded and worn, with a tan and orange color versus the dark blue sides. In the same room, the closet contained three clear bags of clothes and additional clothing in a teal laundry basket on the floor. On 05/20/26 at 1:30 PM, a community bathroom used by residents was observed with toilet paper on the floor that had a brownish substance on it, urine in the toilet, and multiple damp paper towels on the floor. On 05/21/26 at 8:05 AM, the same bathroom was observed with a brownish dirt-like substance on the floor in the shape of shoe prints. The Housekeeping Supervisor stated the housekeeper had probably not gotten to it and that the bathroom should be cleaned and remain clean on a consistent basis, but there was no documentation related to a housekeeping schedule or cleaning log. The Acting Director of Nursing stated the bathroom should be monitored throughout the day and cleaned as needed. On 05/20/2026 at 11:45 AM, the main floor utility sink in the janitor closet was observed connected directly to the chemical dispensing system without a required backflow protection device installed at the faucet.
Insufficient Towels and Laundry Supply
Penalty
Summary
The facility failed to ensure an adequate supply of towels for residents, affecting all 35 residents in the facility. A complaint to the State Agency stated there were no linens, including towels, until late afternoon and that staff were expected to use rags to clean patients; it also stated a hospice nurse could not care for a patient due to the lack of linens. During survey observations and interviews, a CNA reported the supply of towels had run short off and on, the linen closet was found empty of towels, and additional towels and other linens were later found stored in an office on the second floor, with only five towels observed there. The Housekeeping Supervisor stated the facility was waiting on additional clean towels from a laundry drop-off from a sister facility and confirmed both washers were not operating, with laundry sent out about three times per week to be washed. The Acting DON confirmed both facility washing machines were offline and stated the expectation was for all residents to have towels as needed.
Late Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide Advance Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) at least 48 hours before Medicare coverage ended for one resident, R34, out of three residents reviewed for beneficiary notice. The record showed that therapy services were scheduled to end on 4/4/26, but both the NOMNC and SNF/ABN forms were signed by R34 on 4/3/26, only one day before services ended. During interview on 5/21/2026, R34 stated they had been signing a lot of papers and their memory was not as good as it used to be. The medical record showed R34 was admitted and later readmitted with osteomyelitis of the left ankle and foot, and the MDS assessment noted intact cognition. The Business Office Staff stated they were notified on 4/2/26 that coverage was ending and delivered the forms to R34 on 4/3/26, acknowledging the notice was supposed to be given at least two days before coverage ended.
Incomplete Care Plans for Restorative Services, Medication Refusal, and Smoking
Penalty
Summary
The facility failed to develop care plans that addressed the complete care needs and behaviors of three residents whose records were reviewed. R13 was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, and hypertension, and had a BIMS score of 00 indicating severely cognitively impaired cognition. Although R13 was referred to restorative therapy three times a week for twelve weeks on 2/18/26, no care plan or restorative treatment records were found in the chart. The Social Worker stated there had been a recent transition in systems and the care plan may not have been carried over, and the Acting DON reported being unaware that R13 was receiving restorative services. R15 was admitted with diagnoses of cerebral infarction, benign prostatic hyperplasia, and adjustment disorder with mixed disturbance of emotions and conduct, and was cognitively intact. The record showed that R15 refused medications daily for several months, and the care plans reviewed did not include a focus on refusal of care. R34, who had diagnoses of diabetes and high blood pressure, was identified by the facility as a smoker, was reported by the Social Worker as someone seen smoking, and was observed smoking on the patio outside the dining room. The active care plan for R34 did not include a smoking-related care plan, and the Acting DON stated that a smoking care plan should have been in the plan of care, but a copy was not provided prior to survey exit.
Failure to Provide and Document Restorative ROM Services
Penalty
Summary
Failure to provide and document restorative exercise services affected two residents who had therapy recommendations for range of motion and muscle strength maintenance. One resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, had a BIMS score of 00 indicating severe cognitive impairment, and was referred to restorative therapy on 2/18/26 for three times a week for twelve weeks. No documentation of restorative treatments was found, and the restorative aide reported the resident had not been on the caseload or received restorative services. The Acting DON stated staff were unaware the resident was supposed to be on the restorative caseload. A second resident, admitted with right-side paralysis, high blood pressure, and depression, was observed in bed leaning to the left and feeding themself from a tray positioned on the left side of the bed. Therapy evaluations documented impaired upper and lower extremity strength and recommended a restorative nursing program to maintain ROM and muscle strength. The restorative care program called for active and active-assisted ROM exercises to both upper and lower extremities for 15 repetitions, three times a week for twelve weeks, but the EMR contained no current or cancelled restorative program or notes. The active care plan and stroke care plan contained no interventions or revisions for restorative services or ROM exercises, and the restorative aide reported services had not been documented and staffing shortages limited restorative care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted professional principles. In the high medication cart, a bottle of vitamin D was found with an expiration date of 05/2025, and a container of glucose strips was not dated when opened. In the low medication cart, an umeclidinium 0.0625 mg dry powder inhaler was not dated when opened on either the box or the inhaler. In the medication room refrigerator, a tuberculin vial was found dated opened [DATE] and expired. The medication room door was also observed not to be latched and could be opened without turning the handle or using a key. The door remained unlatched and closed at 12:50 PM and 2:24 PM. LPN H stated the medication room door was supposed to be closed. The DON reviewed the concerns and stated the tuberculin vial was good for thirty days after opening, the inhaler should have been dated when opened, and the medication room door should be latched and locked. A policy related to medication storage and labeling was requested but not received prior to survey exit.
Failure to Document Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRRs) for nine residents over a 12-month period, as required by facility policy and federal regulations. Surveyors found that for each of the nine residents reviewed, there was no documentation of MRRs in the electronic medical record, despite these residents having complex medical histories and being prescribed multiple daily medications, including psychotropics, antipsychotics, antiseizure medications, opioids, and insulin. The absence of MRR documentation was confirmed through record reviews and interviews with facility staff. Specific examples included residents with diagnoses such as schizophrenia, bipolar disorder, depression, dementia, diabetes, and heart disease, all of whom were receiving multiple medications daily. For instance, one resident with anxiety, depression, diabetes, and stroke was administered 13 medications daily, including antiseizure and antipsychotic drugs, with no MRRs documented for the past year. Another resident with schizoaffective disorder, bipolar disorder, and hypertension was also found to have no MRRs documented, despite being on 12 daily medications, including antipsychotics and antihypertensives. When surveyors requested the missing MRRs from staff, including the infection control preventionist and corporate consultant, staff indicated that the reviews may not have been scanned into the medical record and would investigate further. However, no MRRs were provided or uploaded into the electronic medical record before the survey concluded. The facility's policy required pharmaceutical services to meet each resident's needs and comply with state and federal requirements, but the lack of MRR documentation demonstrated a failure to follow these procedures.
Failure to Date Resident Food and Monitor Refrigerator Temperature
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items brought in from outside for residents were properly dated and that the temperature of the resident refrigerator was consistently monitored. During inspection, the resident refrigerator in the break room was found without a visible thermometer, and the temperature log had not been updated for nearly three weeks. Additionally, three food containers inside the refrigerator were undated. When questioned, the Dietary Manager indicated that responsibility for monitoring the refrigerator had shifted from dietary to housekeeping, and later confirmed that the thermometer was found buried under food containers and the temperature log was not current. Facility policy requires all prepared food brought in by family or visitors to be labeled with content and date, which was not followed in these instances.
Failure to Maintain Home-Like Environment Due to Persistent Odors
Penalty
Summary
Surveyors observed a strong and persistent urine odor throughout the facility, including upon entry, on the ramp to the upper level, and in hallways leading to resident rooms, all of which were carpeted. The odor was noted at multiple times over two consecutive days. When questioned, the Maintenance Supervisor was unsure of the carpet cleaning schedule and only after consulting with corporate staff stated that carpets are cleaned every six months by an outside company, but could not provide documentation or an invoice for the last cleaning. Additionally, the facility was unable to provide a policy for cleaning carpets or maintaining a home-like environment by the end of the survey. These findings demonstrate a failure to maintain a home-like environment free of offensive odors, as required, with the potential to affect all residents, staff, and visitors.
Deficient Water Management and PPE Use for Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program, specifically in relation to its Water Management Plan (WMP) and the use of Enhanced Barrier Precautions (EBP). Upon request, the Administrator provided a Legionella Surveillance policy and a Water Management Program document, but the latter was a generic template not tailored to the facility. The WMP lacked essential components such as a diagram or description of the building water system, a risk assessment, identification of areas where Legionella could proliferate, control points, monitoring evidence, and documentation of routine water management team meetings. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of involvement and understanding regarding the WMP, with both staff members being relatively new and unable to provide details about the program or its primary prevention strategies. Additionally, nursing staff did not consistently use appropriate PPE for EBP. During an observation, an LPN entered a resident's room with an EBP warning sign indicating the need for gown, gloves, and mask during high-contact activities, but failed to don any PPE while checking a feeding tube. The LPN was unaware of the EBP signage and unsure about PPE requirements for tube feeding placement checks. The Unit Manager confirmed that staff are expected to know the location of precaution signs and the corresponding PPE requirements, while the NHA/DON stated that PPE should be worn during high-contact activities to prevent infection control issues.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required eight hours of Registered Nurse (RN) coverage within a 24-hour period, as evidenced by a review of daily staff postings and timecard reports. Specifically, on May 27, there was not eight hours of RN coverage, and in June, RN coverage was missing for 13 out of 30 days. In July, RN coverage was missing for two out of the first ten days. The Director of Nursing (DON), who also served as the Nursing Home Administrator (NHA), acknowledged shared responsibility for ensuring RN coverage with a Unit Manager RN, and reported ongoing difficulties in maintaining stable staffing due to frequent call-ins. Requested documentation of staffing policies and RN coverage was not provided prior to the survey exit. All 37 residents in the facility were potentially affected by this deficiency.
Failure to Label Multi-Use Medications with Open Dates
Penalty
Summary
Surveyors observed that two multi-use, single resident ophthalmic medications (Restasis and Atropine Sulfate) stored in a medication cart were opened but not labeled with the date they were opened. During the review, an LPN confirmed that medications intended for single resident use should be labeled with both the resident's name and the date the medication was opened. The unit manager and the director of nursing both verified that the facility's expectation is for multi-use medications for single resident use to be dated upon opening. Additionally, when requested, the facility was unable to provide a policy regarding medication storage and labeling by the end of the survey. These findings indicate that the facility did not ensure all multi-use medications for single resident use were properly labeled with an open date, as required by professional standards and facility expectations.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
A resident with dementia and insomnia, identified as being at risk for elopement and having impaired cognition, was able to exit the facility unsupervised through a dining room door. The door alarm, which was intended to alert staff to unauthorized exits, was not functioning properly at the time of the incident. Staff became aware of the resident's absence only after a neighbor notified them that the resident was walking down the street. The resident was subsequently retrieved by staff and brought back to the facility. Review of facility records indicated that the door alarm had last been checked several days prior to the incident, and maintenance staff were unaware of the malfunction. The area where the resident exited was only partially fenced and the door did not have a lock. Staff interviews confirmed that the resident was known to be an elopement risk and that supervision was momentarily interrupted during a shift change, which coincided with the resident's exit. The facility's policy requires adequate supervision and functioning safety measures for residents at risk of wandering or elopement, which were not in place at the time of the event.
Failure to Maintain Homelike Environment and Backflow Protection
Penalty
Summary
The facility failed to maintain a homelike environment in the resident showers and ensure the ice machine on the first floor was backflow protected. Observations revealed that the ice machine drain line extended approximately 2 inches into the floor drain, which had a buildup of black mold. Additionally, the sink in the same room had lime build-up around the faucet aerator. Further observations of the facility's two shower rooms showed black mold and an unknown brown substance around the perimeter and on the walls of the showers. These findings were acknowledged by the Nursing Home Administrator, who indicated she would look into the concerns. The facility's policy on maintaining a safe and homelike environment was reviewed, highlighting the need for housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment.
Resident Transported in Undignified Manner
Penalty
Summary
The facility failed to transport a resident, identified as R901, from a doctor's appointment in a respectful and dignified manner. On the day of the incident, the resident was scheduled for a medical appointment for their foot. The transportation van was an hour and a half late for both the pickup and return trips. During the return trip, the van driver had two children without car seats in the vehicle, and the driver was observed cursing and hitting the children. The office manager at the doctor's office confronted the driver, who then cursed at the manager. Despite the inappropriate behavior, the resident was allowed to ride back to the facility with the children in the van. The resident reported being hit by the children with a book during the ride and that the children were cursing. The Nursing Home Administrator (NHA) was informed of the incident later that evening but did not follow up with the resident or their interested party regarding the situation. The facility's transportation policy outlines the need for safe and comfortable transportation, prohibiting personal use of facility vehicles, and addressing unsafe and abusive conduct. The policy also emphasizes preserving resident dignity, which was not upheld in this incident. The resident, who has a medical history including osteomyelitis, a pressure ulcer, and diabetes with a foot ulcer, was dependent on staff for activities of daily living and had intact cognition at the time of the incident.
Failure to Consistently Apply Wound Vac for Resident
Penalty
Summary
The facility failed to ensure that a wound vac was consistently applied for a resident who was reviewed for skin management. The resident, who had a history of osteomyelitis, pressure ulcer, and diabetes with a foot ulcer, was observed without a wound vac on their left foot after returning from a doctor's appointment. The wound vac was found in a bag with dried blood in the drainage tube and a large amount of blood in the reservoir. The resident's sister confirmed that the wound vac was removed at the doctor's office because the facility did not send the necessary supplies, and the Director of Nursing (DON) was supposed to reapply it the following morning. The Medication Administration Record (MAR) for the resident showed multiple instances where the wound vac was not documented as being applied, including specific dates where it was noted that the resident did not have a wound vac. The facility's policy on wound treatment management requires that wound treatments be provided in accordance with physician orders, but this was not adhered to in this case. The Nursing Home Administrator confirmed that the necessary supplies were not sent to the appointment, leading to the wound vac not being reapplied as required.
Inadequate Documentation of Showers for Dependent Residents
Penalty
Summary
The facility failed to adequately document showers for two dependent residents, R903 and R904, as part of maintaining complete medical records. Concerns were raised about the adequacy of showering and grooming for female residents. During an observation, R904 was found in bed, confused, and unable to communicate effectively. R904's medical record indicated a need for extensive to total assistance with activities of daily living due to conditions such as Dementia, Schizoaffective Disorder, and Diabetes. The review of R904's records showed only three shower sheets for a 60-day period, with two instances of refusal documented. R903 was also observed in bed and expressed uncertainty about their last shower. R903's medical record showed a need for limited to extensive assistance with activities of daily living due to a Traumatic Brain Injury, Dysphagia, and Chronic Kidney Disease. However, no shower documentation was provided for R903. The Nursing Home Administrator acknowledged the lack of documentation, which was not in compliance with the facility's policy on activities of daily living, which mandates necessary services for maintaining personal hygiene.
Inadequate Infection Control Program Documentation
Penalty
Summary
The facility failed to provide evidence of a comprehensive infection prevention and control program that included outcome and process surveillance, accurate data collection, documentation, and analysis. This deficiency potentially affected all 32 residents residing in the facility. During an interview, the Nursing Home Administrator (NHA) reported that the Director of Nursing (DON) was not present at the facility and that the infection control program documentation was with the DON, who was on vacation. Upon review, the Infection Control Program book lacked documentation of comprehensive surveillance and data analysis. The facility's policy stated that the designated Infection Preventionist is responsible for overseeing the program and consulting staff on infectious diseases, but the necessary documentation was not available at the facility.
QAPI Committee Meetings and Membership Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met quarterly and was composed of the required committee members, potentially affecting all 33 residents residing in the facility. During a QAPI review, it was found that the sign-in sheets for the QAPI committee meetings were missing for several months, and when meetings did occur, they lacked the presence of key required members such as the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Specifically, there were no sign-in sheets for meetings in July, August, September, and October 2023, and the meetings in May and June 2023 did not include the NHA or DON. Additionally, the meetings in November and December 2023 only had the Medical Director and a representative from Pharmacy present, and the February 2024 meeting included the Medical Director, Activities, Pharmacy, and the Minimum Data Set (MDS) nurse but still lacked other required members. The current NHA, who assumed the role on May 1, 2024, was unable to explain the missing meetings and required members. The facility's QAPI policy mandates that the QAA Committee be interdisciplinary and consist of the Director of Nursing Services, the Medical Director or designee, at least three other members of the facility's staff (including the Administrator, Owner, Board Member, or another individual in a leadership role), and the Infection Preventionist. The policy also requires the committee to meet at least quarterly. The failure to adhere to these requirements was identified during the review, highlighting a significant lapse in the facility's QAPI processes.
Failure to Implement Enhanced Barrier Precautions and Water Management Plan
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents identified with an indwelling urinary catheter device and skin impairment. Observations revealed that there was no signage for enhanced barrier precautions and no personal protective equipment other than gloves in or outside the rooms of the affected residents. One resident with an indwelling urinary catheter had no enhanced barrier precautions in place, and another resident with chronic wounds and cellulitis also lacked the necessary precautions. The care plans for these residents documented their conditions and the need for specific precautions, but these were not implemented as required by the facility's policy. Additionally, the facility's infection control surveillance was found to be lacking. The Director of Nursing, who also served as the Infection Control Preventionist, had been certified in June 2024 and had been working with the infection control program since January 2024. However, a review of the program documentation revealed no departmental surveillance documentation from May 2023 through December 2023. This indicates a significant gap in the facility's infection control practices and monitoring. The facility also failed to implement an active water management plan to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The Administrator provided a company policy for Legionella surveillance but admitted that there was no water management program tailored to the specific building. The Maintenance Supervisor was unable to provide any information about a water management program, risk assessment, or a description of the building's water system, indicating a lack of preparedness and oversight in managing waterborne pathogens.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were conducted regularly for four residents, leading to a deficiency in the development and implementation of person-centered care plans. Resident R2, who has diagnoses including high blood pressure, stroke, and schizoaffective/bipolar disorder, had care conferences documented on 04/05/23 and 09/26/23, with the next one due on 01/14/24. However, no additional care conferences were completed as per the progress notes. Similarly, Resident R8, with diagnoses including schizoaffective disorder and dementia, had the last care conference on 02/28/23, with the next one due on 05/29/23, but no further care conferences were documented. Resident R20, with diagnoses including schizoaffective disorder and Parkinson's disease, had the last care conferences on 11/17/22 and 02/28/23, with no further documentation of care conferences completed. Resident R23, who has chronic kidney disease, diabetes, and vascular dementia, was also found to have missing care conferences. The last quarterly care conference for R23 was held on 10/30/23, with the next one due on 01/28/24. The facility's social worker admitted that care conferences had not been completed but were being scheduled for the current month. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both confirmed that it is the facility's expectation to hold care conferences quarterly, but this was not adhered to. The facility's policy on care planning and resident participation, revised on 02/22/24, outlines the importance of informing residents and their representatives about their care plans and involving them in the decision-making process. The policy also emphasizes the need for regular care plan conferences and documentation. However, the facility failed to comply with its own policy, resulting in missed care conferences for the residents reviewed, thereby not ensuring their participation in the development and implementation of their person-centered care plans.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up and document physician notification of pharmacy recommendations from medication regimen reviews for four residents. For Resident 2, the clinical record showed diagnoses including high blood pressure, stroke, and schizoaffective/bipolar disorder. The care plan indicated a risk for adverse consequences related to antipsychotic and antianxiety medication. Despite pharmacy concerns identified in medication regimen reviews dated August 2023 and February 2024, the actual reports were not received prior to the survey exit. Similarly, for Resident 8, who had diagnoses including schizoaffective disorder and dementia, the care plan documented a risk for adverse consequences related to antipsychotic medication. Pharmacy concerns were identified in reviews dated June 2023, August 2023, and February 2024, but the actual reports were not received, and it could not be determined if the concerns were addressed as the physician did not acknowledge the recommendations. For Resident 15, who had diagnoses including dementia and mood disorder, the pharmacy recommended monitoring Depakote levels every six months. However, lab results were not received by the end of the survey, and the Director of Nursing acknowledged the expectation that pharmacy reviews should be completed and followed up by the physician. Resident 23's case was not detailed in the report. The Nursing Home Administrator also confirmed the expectation for timely completion and follow-up of pharmacy reviews. A policy related to pharmacy reviews was requested but not received prior to the survey exit.
Failure to Maintain Effective Contact with Resident Representative
Penalty
Summary
The facility failed to obtain and maintain effective contact with the resident representative for a resident with multiple hospitalizations and significant medical conditions, including advanced dementia, chronic PEG tube for primary nutrition, and chronic obstructive pulmonary disease. Despite numerous attempts by various staff members, including social workers, nurses, and the activities director, the emergency contact listed for the resident was unreachable due to a busy signal or no answer. This lack of contact persisted over several months, during which the resident experienced multiple medical events, including hospital transfers for suspected aspiration pneumonia, COVID-19 with respiratory distress, and other emergencies. The deficiency was further compounded by the fact that the resident's legal guardian had been suspended, and no new legal representation was obtained. The social worker revealed that the guardianship process, which should have been initiated in 2021, was not pursued due to time constraints and the need for a filing fee from corporate. The Director of Nursing indicated that the expectation was for social work to take proper steps to obtain legal representation when an emergency contact could not be reached. However, this did not occur, leaving the resident without appropriate legal oversight and unable to make medical decisions independently.
Failure to Develop Elopement Baseline Care Plan
Penalty
Summary
The facility failed to develop an elopement baseline care plan for a resident who was admitted with diagnoses including Unspecified Dementia, Brief Psychotic Disorder, and Paranoid Personality Disorder. The resident was severely cognitively impaired and required supervision for ambulation. Despite being assessed as at risk of elopement, the baseline care plan did not include measurable goals and interventions to address the resident's priority risk factors and individual needs. This omission led to an incident where the resident left the facility and was found outside, although unharmed. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the door alarm went off when the resident exited the building. The Nursing Home Administrator and the Director of Nursing both acknowledged that baseline care plans should be completed within 48 hours of admission, as per the facility's policy. However, the review of the resident's baseline care plan showed that it lacked the necessary instructions to provide effective and person-centered care, contributing to the resident's elopement incident.
Failure to Implement Behavioral Management Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for behavioral management of a resident on psychotropic medication. The resident, who has diagnoses including Schizophrenia, Malignant Neoplasm of Brain, and Diabetes Type 2, was observed in various states of restlessness and calmness. Despite being prescribed antipsychotic and antianxiety medications, there was no care plan addressing psychiatric behaviors or behavior related to these medications. The resident's Basic Interview for Mental Status (BIMS) score suggested moderate cognitive impairment, and their Minimum Data Set Assessment (MDS) indicated no mood or behavior concerns. During a Resident Council meeting, the resident became restless but calmed down when informed of a visit from their sister. The Director of Nursing (DON) confirmed that alternative measures to pharmacological intervention should be tried and documented before administering antipsychotic medication, as per the facility's Behavioral Health Services policy. However, the care plans lacked documentation of such alternative measures, leading to the deficiency.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to thoroughly complete a discharge summary for a resident who was transferred to another long-term nursing facility. The resident, who had diagnoses of Alzheimer's Disease, Heart Disease, and Hypertension, was discharged without a discharge summary or recapitulation of stay documented in the medical record. The resident's transfer was noted in progress notes, but the necessary discharge documentation was missing. Upon request for the discharge summary, the Nursing Home Administrator confirmed that the facility did not have a discharge summary for the resident and acknowledged the expectation that such a summary should be completed. The facility's Discharge Planning Process policy mandates that the evaluation of the resident's discharge needs and discharge plan be documented timely in the clinical record and that all relevant information be provided in a discharge summary to assist the resident in adjusting to the new living environment.
Failure to Follow Medical and Dental Recommendations
Penalty
Summary
The facility failed to follow a hospital recommendation, a physician's order, and follow up on a dental consultation for two residents. Resident R23, who has diagnoses including Chronic Kidney Disease, Diabetes, Chronic Obstructive Pulmonary Disease, and Vascular Dementia, was admitted to the facility after a hospital stay where a neurology consultation recommended an MRI and a follow-up with neurology. Despite a physician's order dated 3/15/24 for a follow-up with neurology in one week, the facility did not have an MRI for R23, as confirmed by the Nursing Home Administrator and the Director of Nursing. Resident R8, diagnosed with Schizoaffective Disorder Bipolar type, Anxiety, Dementia, and Depression, had a dental visit on 4/29/24 that recommended full mouth extractions before proceeding with denture impressions. The facility failed to document any contact with the responsible party or a consult to an oral surgeon for the extractions. A request for documentation of the referral on 6/13/24 revealed that no consultation or referral had been made for R8.
Failure to Supervise and Assess Fall Interventions
Penalty
Summary
The facility failed to supervise and assess the effectiveness of interventions for a resident (R23) who experienced multiple falls, resulting in hospital transfers. R23, who was admitted with diagnoses including Chronic Kidney Disease, Diabetes, Chronic Pulmonary Disease, and Vascular Dementia, was observed to be severely cognitively impaired and required extensive assistance for Activities of Daily Living. Despite these needs, R23 experienced 12 documented falls between January and May 2024, some of which resulted in injuries and hospital transfers. The falls occurred in various locations, including the resident's room, hallway, dining area, and bathroom, and were often unwitnessed or occurred when the resident attempted to self-transfer without assistance. A review of R23's care plan revealed numerous interventions aimed at preventing falls, such as providing toileting assistance, using anti-rollbacks on the wheelchair, and keeping the bed in the lowest position with brakes locked. However, these interventions were not revised following each fall, nor was there documentation addressing the effectiveness of the interventions already in place. The care plan had not been updated to reflect the resident's changing needs or to implement new strategies to prevent further falls. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator revealed that fall events were supposed to be addressed by the Interdisciplinary Team, and the Minimum Data Set nurse was responsible for updating care plans. However, the DON acknowledged that the effectiveness of interventions was an area needing improvement. The facility's Fall Prevention Program policy stated that each resident's risk factors and environmental hazards should be evaluated when developing the comprehensive plan of care, and interventions should be monitored for effectiveness and revised as needed. This was not done for R23, leading to repeated falls and hospital transfers.
Failure to Maintain Orders for Indwelling Catheter Care
Penalty
Summary
The facility failed to obtain and maintain orders for indwelling catheter care for a resident with multiple medical conditions, including chronic schizophrenia, depression/anxiety, dementia, obstructive uropathy with urinary retention, diabetes, and anemia. The resident, who had a BIMS score of 8 indicating moderate cognitive impairment, was observed on multiple occasions with an intact indwelling catheter. However, record reviews revealed that orders for catheter care and changes were discontinued on 6/7/2024, and no new orders were obtained thereafter. On 6/11/2024, the resident was observed in bed with the catheter bag on the bed, and on 6/12/2024, the resident was seen in the dining/activities room with the catheter bag concealed in the pocket of a reclining chair. Despite these observations, there were no active orders for catheter care or changes as of 6/7/2024. The Director of Nursing confirmed that the facility's expectation was to have orders for catheter care and changes documented in the medical record whenever a resident has an indwelling catheter, which was not adhered to in this case.
Failure to Ensure PRN Psychotropic Medications Had Adequate Indications and Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had adequate indications for use and a stop date for one resident. The resident, who had diagnoses including Schizophrenia, Malignant Neoplasm of Brain, and Diabetes Type 2, was observed in bed and later in the activities/dining room. A record review revealed that the resident had two PRN antipsychotic medication orders for Haldol and Lorazepam, both lacking a reason for administration and a 14-day stop date. The Director of Nursing confirmed that it was the expectation for nursing staff to obtain clarification for incomplete orders. Interviews with two LPNs corroborated that orders for antipsychotic medications should include a reason and a stop date. The deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's medication management protocols.
Failure to Control Urine Odors and Ensure Adequate Ventilation
Penalty
Summary
The facility failed to ensure adequate ventilation and control of urine odors, as observed by surveyors on multiple occasions. Upon entry into the facility, a strong odor of urine and damp air was noted. Specific rooms, including room eleven and the entry between certain rooms, consistently had a strong urine odor. The resident bathroom also had a pungent urine odor. A resident reported that their room often smelled like urine, and staff acknowledged the chronic nature of the odor. The bathroom vent in room eleven was found to be ineffective, as it did not actively draw air when tested. The maintenance person confirmed that the vents were simply ducts venting to the roof, which did not provide adequate ventilation. The urine odor was observed to be stronger when the floor was mopped, and a housekeeping supervisor was seen cleaning up an unexpected urine spill in room eleven. Despite these efforts, the urine odor persisted in the room of a resident and the main entry area. The Nursing Home Administrator stated that she expects a clean and odor-free environment, but the facility's policy on maintaining a safe and homelike environment, which includes minimizing odors and ensuring adequate ventilation, was not effectively implemented. The policy review revealed that unresolved environmental concerns should be reported to the Administrator, and adequate outside ventilation should be provided through windows or mechanical means, which was not the case in this instance.
Facility Fails to Maintain Safe and Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure food items and the kitchen were maintained in a safe and sanitary manner, potentially affecting all residents. During a tour of the kitchen, several issues were observed, including a large can of beans with rust on the bottom rim, rusted cans of fruit, and an open bag of pizza rolls in a chest freezer. The chest style vegetable freezer had significant frost build-up and a hard, non-pliable top seal, while the upright meat freezer had frost and ice buildup, rust, and spilled blood on a shelf. The chest style dairy freezer also had substantial frost build-up. The holding refrigerator contained warm food items, indicating it was not functioning properly, and had rust patches and ice buildup. The dietary manager acknowledged these issues but did not take immediate corrective action. Additional observations included a screen door propped open with milk crates, which the dietary manager explained was due to the kitchen getting warm. Half-pint milk containers in the beverage refrigerator were sticky and stuck together. The wall behind the steam table had peeling paint, and soil, food particles, and a straw wrapper were found at the base of the wall. Uncovered and uncooked rolls were left on a sheet pan on top of the steam table, and food debris was observed on top of standing plastic bins for cornmeal, flour, and sugar. The dietary manager later reported that the holding refrigerator was not working and would no longer be used. The Director of Nursing (DON) confirmed that the expectation was for meals to be served and the kitchen to be maintained in a safe and sanitary manner. A review of the facility's policies on food safety and cooler/freezer temperature monitoring revealed that the facility did not adhere to its own guidelines, which included maintaining proper food storage temperatures, monitoring equipment daily, and ensuring food safety practices were followed. The facility's failure to comply with these policies resulted in the observed deficiencies.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure a clean and safe environment, which had the potential to affect all residents. During a facility tour, multiple rooms were found with various issues such as urine odor, clothes piled on the floor, holes in walls, chipped paint, dirty linens, and missing or broken fixtures. Specific observations included a baseboard heater cover that had fallen off, revealing bent and smashed fins, and rooms with significant cleanliness and maintenance issues such as soiled linens, dust buildup, and mold that could not be removed by the Maintenance Director. The Director of Nursing acknowledged these issues and stated that linens should be changed daily or every other day, and that rooms should be clean and comfortable for residents. Additionally, the facility failed to maintain tube feeding equipment in a clean and sanitary condition for one resident. The resident, who had diagnoses including Dementia and Gastrostomy Status, was observed with a significantly soiled tube feed/IV pole. The Director of Nursing confirmed that the equipment should never be as soiled as it was and should be cleaned immediately when it becomes soiled. The facility's policy on Environmental Services indicated that equipment should be cleaned and disinfected during deep cleaning procedures.
Loose Handrails in Upper Hallway
Penalty
Summary
The facility failed to ensure handrails were firmly mounted to the wall in the upper hallway, affecting five residents living in rooms along the hallway. During a tour of the facility, several handrails were observed to be loose and easily jiggled when pressure was applied. Specific locations included the inside corner at the right side of the food service elevator, the right of the kitchen/break room door, the left of the food service lift door, the right side of the office door, and between various rooms and bathrooms. These concerns were acknowledged by the maintenance supervisor and reviewed with the Director of Nursing (DON), who confirmed that the environment should be maintained to ensure resident safety. A policy related to the maintenance of the handrails was requested but not received prior to the survey exit.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 986 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Utica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Shelby Township | 1.9 mi | ★★★★★ | 7 | 0 |
| Shelby Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 10 | 0 |
| Lakeside Manor Nursing And Rehabilitation Center | 2.4 mi | — | 12 | 0 |
| Shelby Crossing Health Campus | 2.4 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Shoreline | 3.2 mi | ★★★★★ | 8 | 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.