Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Greens At Pinehurst Rehabilitation & Living Ce during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for medications for two residents. One resident with bladder dysfunction and urinary retention was coded on a quarterly MDS as receiving an antibiotic during a seven-day assessment period, even though the MAR showed no antibiotic administration during that time, which the MDS coordinator later confirmed as an error. Another resident with dementia, psychotic disturbance, and PTSD was ordered Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR showed it was given; however, the MDS nurse coded this as an antianxiety medication on the MDS, later acknowledging that Hydroxyzine is an antihistamine and that the antianxiety classification on the assessment was incorrect.
A resident with major depressive disorder, generalized anxiety disorder, and PTSD was admitted with a short‑term Level II PASRR approval that had a defined expiration date. The admission MDS showed the resident had not been evaluated and determined to have a serious mental illness, intellectual disability, or related condition under a current Level II PASRR. Facility records contained no evidence that staff submitted a referral to obtain a new Level II PASRR evaluation before the prior approval expired. In interviews, the SW acknowledged that the Level II PASRR had expired without renewal due to an oversight, and the Administrator stated that PASRR evaluations were expected to be monitored and updated before expiration.
A resident with hypertension and constipation had physician orders for Metoprolol and MiraLax via G-tube twice daily, scheduled for administration at 9:00 AM. On one occasion, an agency nurse fell behind on the morning med pass and did not administer these medications until around noon, outside the facility’s one-hour before/after scheduled time requirement. The nurse did not request assistance despite prior instructions for agency staff to do so if they were falling behind. The DON and Medical Director confirmed that medications were required to be given within the established one-hour window and that this expectation was not met, although the resident showed no clinical ill effects.
A resident with dysphagia, gastrostomy status, and aphasia following a stroke was receiving continuous enteral feeding and scheduled water flushes via G-tube. A nurse administered medications through the G-tube using a syringe she had noticed was discolored, then rinsed it with water, separated the syringe and plunger, and stored them in a plastic bag without allowing them to air dry. Later observation found the syringe tip and lower barrel coated with thick, crusted yellow material and the storage bag containing water droplets with pooling. The DON stated the syringe should have been washed, allowed to dry before storage in a dry bag, and that a stained syringe should have been discarded and replaced. This practice had the potential to cause bacterial growth and contamination.
Surveyors found that the ADON failed to follow infection control policies for hand hygiene and glove use while performing wound care on two residents under enhanced barrier precautions for wounds and, for one resident, an indwelling urinary catheter. The ADON did not perform hand hygiene before donning gloves, did not change gloves or perform hand hygiene between removing soiled dressings and applying clean dressings, and placed soiled dressings and used gauze on clean barriers next to unused supplies. She also exited a room wearing a gown, retrieved supplies from the hallway, reentered without hand hygiene, and continued wound care without appropriate glove changes, contrary to facility policies requiring hand hygiene at specified points and proper handling of soiled and clean items.
The facility failed to ensure residents and their representatives were routinely invited to participate in care planning. A cognitively intact resident and the resident’s representative were not included in multiple care plan meetings, and the resident reported never being invited or informed about such meetings despite wishing to participate. Another resident with dementia and multiple comorbidities had a representative who received only one invitation to a care plan conference and was unaware that regular care plan reviews should occur. The SW reported she had only been organizing 72‑hour post‑admission or concern‑driven meetings, was unaware she was responsible for scheduling routine quarterly and annual care plan conferences based on the MDS calendar, and confirmed these had not been completed for all residents. The administrator acknowledged learning that required quarterly and annual care plan meetings and invitations for residents and representatives had not been carried out as expected.
A dependent resident with a contracted hand and reduced mobility, care planned as needing assistance with personal hygiene and documented on MDS as dependent for personal hygiene, did not receive appropriate fingernail care. Over multiple observations, the resident’s fingernails remained long, jagged, and soiled, despite the resident’s stated preference for short nails and reports that long nails caused discomfort by stabbing into the contracted hand. Bath and skin review documentation addressed only toenails, and weekly skin assessments lacked fingernail documentation. The assigned NA acknowledged not providing or offering nail care during a bed bath, and nursing staff interviews confirmed that nail care oversight during weekly skin assessments and routine hygiene was not carried out for this resident.
A resident with intractable epilepsy and moderately impaired cognition had physician orders and a care plan directing scheduled anti-seizure medications via G-tube to be given at specific morning times. On one morning, an agency nurse fell behind on medication administration and did not give the resident’s 8:00 AM and 9:00 AM anti-seizure doses until shortly after noon, 3–4 hours late and outside the facility’s one-hour before/after policy window, and did not request assistance despite prior instruction that agency staff should do so if behind. Review of the MAR, interviews with the nurse, DON, and Medical Director, and the resident’s record confirmed the delay and that the medications were not administered as ordered, although the resident showed no documented clinical ill effects.
The facility failed to accurately post and maintain daily nurse staffing information, with multiple days where the posted counts of NAs, an RN, and LPNs did not match the actual staffing schedule, including miscounts and misclassification of an RN as an LPN. The Scheduler acknowledged not updating postings when staff called out, did not show, or when coverage staff arrived. On at least one observed day, the daily staffing sheet in the reception area was not current, displaying an outdated date instead of the day’s staffing, while the Scheduler and DON each believed the other had ensured proper posting, and leadership later suggested the sheet may have been removed and not replaced.
The facility failed to date leftover food items in the dry goods storage area and walk-in cooler, as observed during a survey. Issues included undated corn flakes, brown sugar, sliced cheese, sliced ham, and cooked mixed vegetables. Staff interviews revealed a lack of adherence to proper food storage protocols, with the new Dietary Manager acknowledging responsibility for ensuring correct dating and storage.
The facility failed to accurately code MDS assessments for falls for three residents. One resident with vascular dementia had a fall with a minor injury that was not recorded. Another resident with a history of stroke and repeated falls had multiple falls, but only one was recorded. A third resident with dementia had two falls without injuries, which were not reflected in the assessments. The MDS Coordinator confirmed these were oversights.
Expired Latanoprost eye drops were found in a medication cart during an observation at an LTC facility. Nurse #1 confirmed the medications were expired and removed them. The DON stated that nurses are responsible for checking expiration dates, but there was no set schedule for unit managers to do so. The facility Pharmacist visits bi-monthly to check carts but did not recall which carts were reviewed last.
The facility did not ensure that NAs received their required annual Dementia training, affecting four NAs who had not been trained since June 2023. The DON and Administrator acknowledged the oversight, which was attributed to the SDC's medical leave. The DON confirmed the training should be completed yearly, and the Administrator expected it to be done annually.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for medications for two residents. For one resident with bladder dysfunction and urinary retention, review of the Medication Administration Record (MAR) for a specified seven-day period showed that no antibiotic medications were administered. However, the quarterly MDS assessment for that same assessment period was coded to indicate the resident had received an antibiotic. Upon review of the MDS and MAR, the MDS Coordinator confirmed that the antibiotic entry on the MDS was incorrect and that the resident had not received an antibiotic during the assessment window. For another resident with dementia with psychotic disturbance and PTSD, physician orders directed administration of Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR confirmed the medication was given as ordered throughout the month reviewed. The quarterly MDS assessment, completed by an MDS nurse, documented that the resident was receiving medications from the antianxiety drug classification and included indications for antianxiety use. During interview, the MDS nurse stated the resident was not ordered any medications classified as antianxiety drugs and acknowledged she had coded the resident as receiving antianxiety medications based on the Hydroxyzine order, being unsure of its drug class. After reviewing medication information, she confirmed Hydroxyzine is classified as an antihistamine and acknowledged that coding it as an antianxiety medication on the MDS was an error.
Failure to Renew Expired Level II PASRR Authorization
Penalty
Summary
The facility failed to obtain a new Level II Preadmission Screening and Resident Review (PASRR) evaluation after the expiration of a short‑term approval for nursing home placement for one resident. The resident was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post‑traumatic stress disorder, and the admission MDS indicated the resident had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or related condition. Record review showed the resident was admitted with a Level II PASRR for short‑term admission that had a specific issuance and expiration date, but there was no documentation that the facility submitted a referral for another Level II PASRR evaluation to extend approval beyond the expiration date. In interviews, the Social Worker confirmed that the resident’s Level II PASRR for short‑term admission had expired and acknowledged that she had not submitted a request for another Level II PASRR evaluation, describing the lapse as an oversight that had fallen through the cracks and stating that a new evaluation should have been requested before the temporary one expired. The Administrator stated that she expected PASRR evaluations to be monitored and kept up to date and acknowledged that a review for this resident should have been requested before the expiration date.
Late Administration of Scheduled Medications Outside Required Time Frame
Penalty
Summary
The deficiency involves the facility’s failure to administer scheduled medications as ordered by the physician and within the facility’s required time frame for one resident. The resident was admitted with diagnoses including hypertension and constipation and had active physician orders for Metoprolol Tartrate 25 mg via G-tube twice daily for hypertension, with parameters to hold for heart rate less than 65 or systolic blood pressure less than 100, and MiraLax 17 gm/scoop via G-tube twice daily for constipation. The March 2026 MAR showed both Metoprolol and MiraLax were scheduled for 9:00 AM but were not administered until 12:07 PM on a specific date, outside the facility’s accepted window of one hour before or one hour after the scheduled time. During interview, the nurse who administered the medications stated he was an agency nurse working intermittently at the facility and reported that he fell behind on morning medication administration and did not give the resident’s morning medications until noon. He acknowledged that he did not request assistance to ensure medications were given on time. The DON stated that medications were required to be administered on time, that agency staff had been instructed to request assistance if they fell behind, and that medications should be given within one hour before or after the scheduled time. The Medical Director confirmed that the resident experienced no ill effects and that vital signs remained within normal limits, and he acknowledged the facility’s requirement that medications be administered within the one-hour window and his expectation that staff follow this policy.
Improper Cleaning and Storage of G-Tube Syringe
Penalty
Summary
The deficiency involves the facility’s failure to properly clean and dry a G-tube syringe before storage for a resident receiving enteral nutrition and medications. The resident had diagnoses including unspecified dysphagia, gastrostomy status, and aphasia following a stroke, and received more than half of her total calories from enteral feedings. Active orders included continuous tube feeding at 72 ml/hr over 20 hours with water flushes every 4 hours. Review of the MAR showed that a nurse administered medications via the G-tube in the morning. Later that morning, surveyors observed the resident’s G-tube flush syringe stored in a plastic bag hanging from the feeding pump pole, labeled as changed at midnight. The syringe was separated from the plunger, but the elongated tip and lower third of the barrel contained thick, crusted yellow material, and the storage bag contained water droplets with pooling at the bottom. During interview, the nurse who had administered the medications acknowledged that she had observed the syringe was discolored when she used it earlier. She stated that some medications could stain syringes and reported that she rinsed the syringe with water after use but had no supplies to scrub it. She explained that she separated the syringe and plunger and placed them into the storage bag after rinsing, and she was not aware that the syringe and plunger should be allowed to air dry before being placed into a clean, dry bag. The DON later stated that the syringe should have been washed, the plunger removed to allow drying before storage in a dry bag to prevent bacterial growth, and that the stained syringe should have been discarded and replaced, with G-tube syringes routinely replaced on night shift. The report states that this deficient practice had the potential to cause bacterial growth and contamination.
Failure to Follow Hand Hygiene and Glove Protocols During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during wound care. The facility’s policy required alcohol-based hand rub as the preferred method of hand hygiene when hands are not visibly soiled, and specified hand hygiene before donning gloves, before handling clean or soiled dressings, after handling used dressings or contaminated equipment, and after removing gloves. The enhanced barrier precautions protocol required staff to wear gloves and a gown for high-contact resident activities such as wound care and to perform hand hygiene before and after leaving the resident’s room. During wound care for a resident on enhanced barrier precautions for wounds and an indwelling urinary catheter, the Assistant Director of Nursing (ADON) donned a gown and gloves before entering the room and placed a clean towel as a barrier on the bedside table, then placed clean supplies on it. She removed a soiled dressing from the resident’s right foot and placed it on the clean barrier next to unused supplies, did not remove gloves or perform hand hygiene before cleaning the wound, and then opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene. She then removed a soiled sacral dressing, placed it on the bedside barrier, cleaned the sacral wound, and again opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene between handling soiled items and clean supplies. In a separate observation of wound care for another resident on enhanced barrier precautions for a wound, the ADON donned a gown and gloves without performing hand hygiene before entering the room. She placed a clean towel and clean wound care supplies on the bedside table, repositioned the resident, removed a soiled sacral dressing and left it on the bed, then cleaned the wound and placed used gauze on the towel next to clean supplies. Without removing gloves or performing hand hygiene, she opened collagen with silver, applied it to the wound, and applied a silicone-bordered dressing. She removed her gloves without performing hand hygiene, exited the room wearing the gown, retrieved tape from the wound cart in the hallway, reentered the room without hand hygiene, and donned clean gloves. She then removed a soiled dressing from the resident’s right foot, left it on the bed, and wrapped the foot with a dry dressing without changing gloves or performing hand hygiene between soiled and clean tasks. After completing wound care, she discarded used dressings and the towel, removed her gown and gloves, and washed her hands. These observations showed failure to follow the facility’s infection control policies for hand hygiene, glove changes, and handling of soiled dressings and clean supplies during wound care under enhanced barrier precautions.
Failure to Involve Residents and Representatives in Routine Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with the opportunity to participate in the care planning process as required. For one cognitively intact resident, the 5‑day MDS showed intact cognition, yet review of the electronic health record revealed that neither the resident nor the resident representative were listed as attendees at multiple care plan meetings. In an interview, this resident reported never being invited to a care plan meeting since admission, was unaware that such meetings were held, and stated he would have liked to attend with his daughter to be actively involved in his care plan. The social worker acknowledged that she had not sent invitations to this resident for care planning meetings and confirmed that quarterly or annual care plan meetings with residents and/or representatives had not been completed. For another resident with dementia with psychotic disturbance, PTSD, abnormal weight loss, failure to thrive, and anemia, MDS assessments documented severe cognitive impairment. Records showed that the resident’s representative received only one written invitation to a care plan conference, which occurred in November and was documented as including the representative. The representative confirmed being notified and invited only once and was unaware that routine care plan conferences should have occurred. The social worker stated she had only been sending invitations and holding care meetings for 72‑hour post‑admission residents or when concerns were expressed, and that she was unaware she should have been inviting all residents and/or representatives on a routine basis based on the MDS calendar. She confirmed that quarterly and annual care plan meetings for all residents and/or representatives had not been completed because she did not know it was her responsibility. The administrator stated she had been made aware that annual and quarterly care plan meetings had not been completed for all residents and that residents and/or representatives were not invited to attend care planning meetings, despite her expectation that plans of care be reviewed quarterly and as needed with them.
Failure to Provide Required Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident who required assistance with activities of daily living, including personal hygiene. The resident was admitted with a contracture of the left hand and reduced mobility and had a care plan indicating an ADL self-care performance deficit, with dependence on staff for personal hygiene. A significant change MDS documented the resident as cognitively intact, without rejection of care, and dependent on others for personal hygiene. Bath skin review sheets for multiple dates documented only toenail condition, with no reference to fingernails. During observations on two consecutive days, the resident’s fingernails on both hands were noted to be jagged or broken, extended more than 1/4 inch past the fingertips, and had a brown substance underneath the free edge of the nails. The left hand fingers were curled inward due to contracture, though no wounds were observed in the palm when the resident uncurled the fingers using the right hand. In interviews, the resident stated a preference for short fingernails, especially on the contracted left hand, explaining that long nails often stabbed into the palm and caused discomfort. The resident reported that NAs sometimes cleaned under her nails but no one had offered to cut them, and later confirmed that although she received a bath, her fingernails were not cleaned. The NA assigned on one of the observation days acknowledged typically checking nails during baths but admitted she did not provide or offer nail care during the resident’s bed bath that morning and did not provide a reason. Nurse #1 stated that it was the assigned nurse’s responsibility to ensure nail care was provided and that nurses were supposed to complete a nail review during weekly skin assessments, but was unsure when the resident was due for such an assessment. Review of the weekly skin assessments showed no documentation regarding the resident’s fingernails on the last recorded assessment, and the DON stated she expected NAs to provide nail care on bath days and had designated an NA to complete weekly nail inspections, but was unsure how this resident’s nail care had been missed.
Late Administration of Anti-Seizure Medications by Agency Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when scheduled anti-seizure medications were not administered as ordered. Resident #12, admitted with intractable epilepsy without status epilepticus and with moderately impaired cognition, had active physician orders for Lacosamide 150 mg twice daily via G-tube, Levetiracetam 1000 mg every morning and at bedtime via G-tube, and Phenytoin Sodium Extended 100 mg twice daily via G-tube. The resident’s care plan included an intervention to give anti-seizure medications as ordered by the physician. The March 2026 MAR showed that Phenytoin Sodium Extended 200 mg was scheduled for 8:00 AM, Lacosamide 150 mg for 9:00 AM and 5:00 PM, and Levetiracetam 1000 mg for 9:00 AM and 9:00 PM. On 3/16/26, Nurse #2, an agency nurse who worked intermittently at the facility, did not administer the resident’s scheduled 8:00 AM and 9:00 AM anti-seizure medications until 12:07 PM, resulting in the medications being given 3 to 4 hours late and outside the facility’s acceptable one-hour before/after administration window. In an interview, Nurse #2 stated he fell behind on morning medication administration and did not request assistance to ensure medications were given on time. The DON stated that seizure medications were required to be administered on time, that agency staff had been instructed to request help if they fell behind, and that she was unaware the medications had been given outside the acceptable timeframe. The Medical Director confirmed the late administration of the anti-seizure medications and noted that, although the resident did not appear to have suffered ill effects and vital signs remained within normal limits with no documented seizure activity, the delay could have increased the resident’s risk for seizure activity.
Failure to Accurately Post and Maintain Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information and to ensure that the posted information matched the actual staffing schedule. Record review of 30 days of postings compared to the staffing schedules showed discrepancies on 7 days, including incorrect counts of NAs on various shifts and an incorrect count and classification of an RN and LPNs on one day. The Scheduler confirmed that she did not update the posted staffing sheet when staff called out, were no-shows, or when replacement staff came in, and she acknowledged miscounting an RN as an LPN on one shift. The Administrator stated that the daily posted nurse staffing sheet and the nursing schedule should match the number of staff who actually worked each shift. The facility also failed to ensure that the daily staffing sheet was posted on at least one observed day. During the initial tour and a later observation on the same day, the staffing posting in the reception area was dated several days earlier, indicating that the current day’s staffing information was not displayed. The Scheduler stated that she or the DON were responsible for posting the daily staffing sheets on weekdays and believed the DON had posted the sheet that morning. The DON reported that she had posted the sheet early that morning and suggested it might have been removed for review and not replaced. The Administrator reported being told by the DON that the sheet had been posted and suggested it was possible someone removed it and failed to return it to the display area.
Improper Food Storage and Dating in Facility
Penalty
Summary
The facility failed to properly date leftover food items stored in the dry goods storage area and the walk-in cooler, as observed during a survey. Specific issues included an open and undated bag of corn flakes, an undated bag of leftover brown sugar stored in an unsealed plastic bag, an undated leftover package of sliced cheese, an undated leftover package of sliced ham, and a stainless-steel container with cooked mixed vegetables that had not been dated. These observations were made during a survey conducted on December 2, 2024. Interviews with staff revealed a lack of adherence to proper food storage protocols. The Dietary Manager, who was new to the position, acknowledged her responsibility for ensuring food items were dated and stored correctly. Another staff member indicated awareness that refrigerated leftovers should be used within three days and dry goods should be sealed, labeled with an open date, and used within seven days. The Dietary Aide confirmed that food items should be sealed, dated, and checked daily for expiration. The Administrator also acknowledged the importance of sanitary and safe food practices and noted the Dietary Manager's newness to the role.
Inaccurate MDS Coding for Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the area of falls. Resident #63, who was admitted with vascular dementia, experienced a fall with a minor injury on 9/20/24, which was not recorded in the annual MDS assessment dated 11/9/24. The MDS Coordinator confirmed the oversight during an interview. Similarly, Resident #64, with a history of stroke and repeated falls, had multiple falls between 7/5/24 and 8/7/24, but the quarterly MDS assessment dated 9/15/24 only recorded one fall with minor injury. The MDS Coordinator acknowledged the error, stating it was an oversight. Resident #3, diagnosed with dementia, had falls on 7/24/24 and 8/5/24, both without injuries. However, these incidents were not reflected in the quarterly MDS assessments dated 7/31/24 and 9/15/24, respectively. The MDS Coordinator confirmed the omissions during an interview, attributing them to oversight. The facility's Administrator expressed that it was his expectation for MDS assessments to be coded accurately in the area of falls.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to discard expired medications in one of the two medication carts reviewed for storage and labeling. During an observation of the Masters Hall medication cart, it was found that there were three opened bottles of Latanoprost eye drops, all of which were past the manufacturer's recommended discard date of six weeks after opening. Nurse #1 confirmed the medications were expired and removed them from the cart. She admitted to not checking the medication cart for expired medications on the day of the observation. The Director of Nursing stated that all nurses were responsible for checking the dates on multi-use medications before administration to ensure they were not expired. However, there was no set schedule for unit managers to check the medication carts for expired medications. The facility Pharmacist, who visits every other month, also checks the medication carts for expired medications but did not recall which carts were reviewed during the last visit in October. The Pharmacist confirmed the manufacturer's recommendation for discarding Latanoprost eye drops six weeks after opening.
Failure to Provide Annual Dementia Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) received their required annual Dementia training. This deficiency was identified for four NAs, who had not received Dementia training since June 2023. The NAs in question had been employed at the facility for varying lengths of time, with hire dates ranging from December 1999 to December 2022. During interviews, both the Director of Nursing (DON) and the Administrator acknowledged the oversight, attributing it to the absence of the Staff Development Coordinator (SDC) due to medical leave since October 2024. The DON confirmed that the Dementia training should be completed yearly, and the Administrator stated it was his expectation that the NAs receive this training annually.
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What surveyors actually found near you
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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 Pinehurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Joseph Of The Pines Health Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Pinehurst Healthcare & Rehabilitation Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Inn At Quail Haven Village | 2.4 mi | ★★★★★ | 0 | 0 |
| Penick Village | 5.1 mi | ★★★★★ | 3 | 0 |
| Dahlia Gardens Center For Nursing And Rehabilitati | 6 mi | ★★★★★ | 6 | 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.