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 Grand The during CMS and state inspections, most recent first.
Expired medications, loose pills, and improperly handled biologicals were found in multiple medication carts and medication rooms. An LPN and unit managers confirmed items including expired needleless connectors, heparin flushes, IV start kits, TB syringes, safety needles, an EpiPen, and a bisacodyl suppository, along with tuberculin vials that had no open date documented or had been kept beyond the required timeframe. Several carts also contained loose pills in drawers, and one drawer holding expired heparin flushes had no label or signage indicating it was designated for pharmacy return.
Improper freezer food storage and ice buildup. A kitchen walk-in freezer contained partially used, unsealed boxes of breakfast sausage, burger patties, and cod left open to freezer air. Ice buildup on the freezer door frame prevented the door from closing fully, and ice was also observed on several containers of ice cream. A Dietary Aide confirmed the food was open and the buildup was affecting the door closure, then chipped ice away with a kitchen scraper so the door could close.
Bed Equipment and Call Light Accessibility Failures: A resident with lumbar fractures and another resident with multiple mobility-related diagnoses were found with bed equipment that did not fit or function appropriately, including a bed that would not raise flat and a mattress that was too short for the frame. A third resident with Parkinson’s disease and fall risk had a call light attached to the bed rail while seated in a recliner, leaving it out of reach. Staff and family confirmed the bed issues had been ongoing, and an LPN verified the call light was not accessible.
Bathing Preferences Not Honored: A resident with a fracture and morbid obesity was dependent on staff for bathing, but the record showed only two showers over the review period and multiple bed baths without documentation that the resident refused showers. The resident’s daughter and CNAs reported the resident preferred showers, while the DON confirmed there were no documented refusals in the EMR.
Failure to provide privacy during a blood draw. A resident with Alzheimer’s disease, chronic pain syndrome, and osteoporosis, who had severe cognitive impairment and used a wheelchair, had venipuncture performed in a TV room while other residents were present. The phlebotomist confirmed the blood draw occurred in the communal area and stated it was not typical to do so. Facility policy required privacy during venipuncture specimen collection.
Failure to provide adequate bathing and personal hygiene affected three residents who were dependent on staff for ADLs. One resident with DM and CKD had visible chin hair that staff had not offered to shave, another resident with DM and other conditions had fingernails about an inch past the fingertips and reported the facility would not cut them, and a third cognitively intact resident with multiple medical conditions received repeated bed baths instead of showers despite a stated preference for showers, with disheveled and matted hair and no documented refusals for hair care or turning.
A resident with a lumbar fracture, Parkinson’s disease, and moderate cognitive impairment was supposed to wear a TLSO brace while sitting or standing, but surveyors observed the brace improperly positioned and later found off the resident and placed on a trash can. An LPN corrected the brace during one observation, and the resident stated no one had put it on him that day; a unit manager confirmed the brace should have been on the resident, while the TAR indicated it had been documented as applied for the morning shift.
Failure to ensure routine podiatry services for a resident with dementia and severe cognitive impairment. The resident had overgrown, thick, discolored toenails and was supposed to receive ancillary podiatry care, but was not placed on multiple podiatry visit lists and had no podiatry notes for several months. Later, the resident developed a right great toe issue with a partially detached toenail, infection signs, pain, and drainage, while observation still showed markedly overgrown toenails and tenderness in the left great toe.
Fall interventions were not consistently in place for a resident with dementia, Parkinson's disease, impaired mobility, and a history of falls. After the resident reported an overnight fall and was found with an inward-rotated RLE, the care plan and MD orders called for a fall mat, the bed against the wall, and bolsters, but observations showed the bed centered in the room with no fall mat at times, and later no bolsters were present; an LPN confirmed the missing interventions.
Failure to monitor significant weight loss: A resident with CHF, CKD, COPD, and depression had a delayed start to ordered nutritional supplements, then experienced a severe weight loss during a hospital stay for a GI bleed. After return to the facility, no weight was obtained on readmission and no additional weights were taken for weeks, despite the resident denying refusal to be weighed and the RD acknowledging weekly weights would have been optimal. The RD attributed the loss to fluid shifts even though hospital and nursing findings did not show fluid overload, and the resident later weighed even less.
Incorrect Renal/Diabetic Diet Served: A resident with CHF, DM2 with CKD, diabetic retinopathy, and morbid obesity was ordered a renal/diabetic diet, but meal trays did not match the menu. Breakfast included items not on the renal menu and 8 oz of milk instead of 4 oz, lunch included sweet potato fries instead of cauliflower, and staff confirmed the incorrect diet was served.
Infection control failures occurred during incontinence care and with EBP for two residents. A CNA used the same washcloth for multiple body areas, including the peri-area and backside, used improper wiping technique during pericare, and left a resident exposed while leaving to get more washcloths. In another instance, a resident with JP drains and a PICC line had no EBP signage outside the room, and an LPN confirmed the signage was missing despite the resident’s care plan requiring EBP and CDC guidance identifying indwelling devices as an indication for targeted gown and glove use.
Antibiotics were used without adequate clinical indication for two residents. One resident with chronic diarrhea and GI history was given metronidazole to disrupt gut flora and re-bulk stools, even though staff and the CNP confirmed no active infection was suspected and McGeer criteria were not met. Another resident received cephalexin for cystitis after a hospital visit, but there was no culture and sensitivity and the facility’s McGeer worksheet showed the infection criteria were not met.
A resident with Alzheimer's disease, bilateral hearing loss, and a primary language barrier was not provided with appropriate communication aids as outlined in her care plan and facility policy. Staff inconsistently used translation apps, often relied on hand gestures or the resident's daughter for communication, and failed to ensure the resident could effectively express her needs, leading to ongoing frustration and unmet care needs.
Two residents experienced significant medication errors when one received an antibiotic as intermittent infusions instead of a continuous IV infusion as ordered, and another had insulin doses administered late on multiple occasions. Errors resulted from incorrect order entry, lack of proper verification, and failure to document medication administration in real time, contrary to facility policy.
The facility failed to report and investigate allegations of physical abuse in a timely manner, affecting two residents. An altercation between two residents resulted in injuries, and the incident was not immediately reported to the Administrator. Additionally, a resident's representative reported staff-to-resident abuse during a care conference, but these allegations were not investigated or reported. The facility did not adhere to its policy on abuse reporting, leading to a deficiency under two complaint numbers.
The facility failed to investigate allegations of staff-to-resident physical abuse involving two residents. One resident was reportedly held down and flipped during incontinence care, causing pain, while another was allegedly dragged down the hallway by staff. Despite these reports being made during a care conference, no investigation was initiated, and the incidents were not reported to the Administrator, violating the facility's abuse policy.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.89%. A resident was affected when an LPN administered medications incorrectly, including crushing an enteric-coated Aspirin and omitting part of a prescribed Senna-S dose. The errors were confirmed by the LPN and reported to the DON.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, as required. This was confirmed through staffing schedules and staff interviews, revealing several dates without RN coverage. The Director of Nursing (DON) and unit managers were unaware of this regulatory requirement, potentially affecting all 92 residents.
The facility did not designate a licensed charge nurse for the 7:00 A.M. to 7:00 P.M. shift on weekends and holidays, directing staff to an on-call list instead. The DON confirmed that the nightshift supervisor and unit manager cover other shifts, but on weekends and holidays, the on-call manager is only available by phone. There is no specific job description for a charge nurse, and any nurse could be considered in charge of their unit.
The facility failed to maintain safe flooring on the 200 hall, affecting 25 residents, with torn and loose carpet sections identified but not repaired. Additionally, a resident with cognitive impairments had clothing improperly stored in the shower instead of the closet, which was not in line with the facility's policy for a homelike environment.
A resident with multiple health conditions did not receive timely Beneficiary Notices regarding Medicare/Medicaid coverage, leading to a lack of awareness about potential liability for non-covered services. The facility's policy requires advance notice, but the SNF ABN was issued after coverage ended, confirmed by staff interviews.
A resident, who was cognitively intact and had multiple diagnoses, made an abuse allegation against a staff member. The facility's receptionist reported the allegation to the administrator, but it was not reported to the state agency until the next day, violating the facility's policy requiring immediate reporting.
A facility failed to develop a comprehensive care plan for a resident with significant weight loss and nutritional risk. Despite losing 76.8 pounds in three months, no care plan addressed the resident's nutritional status. The clinical dietitian confirmed the absence of an active nutrition care plan, contrary to facility policy requiring timely and updated care plans.
A resident with multiple health conditions, including Parkinson's disease and dementia, experienced a significant delay in receiving podiatry services due to the podiatry group's poor availability. Despite a request made in April for podiatry care due to painful and thickened nails, the resident was not seen until July, leading to frustration and concerns from the resident and their family about the facility's communication and service timeliness.
A resident with multiple medical conditions requiring maximum assistance for transfers was inadequately assisted during a sit-to-stand lift transfer. Despite facility policy requiring two staff members, an STNA conducted the transfer alone, risking the resident's safety. The STNA cited unavailability of other staff as the reason for proceeding alone.
A resident experienced a significant weight loss of 22.6 pounds over six months without proper re-assessment, monitoring, or physician notification. Despite meal intakes being documented as adequate, no root cause analysis was conducted. The resident, who disliked the facility's food, purchased his own meals and refused supplements. The facility's dietitian and DON confirmed the lack of documentation and physician notification.
A resident with dementia and other medical conditions experienced unmanaged pain over two days, despite vocalizing discomfort. Observations and interviews confirmed the absence of pain relief interventions, contrary to the facility's pain management policy.
The facility failed to follow its medication administration policy, which requires dispensing and documenting medications for one resident at a time. Observations revealed LPNs administering medications to multiple residents simultaneously, with one LPN stacking cups of pills and another preparing multiple unlabeled cups. This affected residents with complex medical conditions, and the DON confirmed the policy violation.
A facility failed to secure medications from dispensing to administration, as observed when a resident's medications were left unattended at the bedside. The resident, with multiple diagnoses including Parkinson's and dementia, was not assessed for self-medication. An LPN confirmed this was against standard practice, and the DON stated medications should not be left unless self-medication is approved. Facility policy requires medications to be secured unless under direct nurse supervision.
A facility failed to document communication between hospice and facility staff for a resident on hospice care. Despite the resident's complex medical history, there was no record of hospice visits or communication since admission to hospice. Staff interviews confirmed the absence of documentation, although verbal communication was reported.
A facility failed to adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic use for a resident. Despite the absence of microorganisms in the urine culture and not meeting the criteria for a UTI, the resident was prescribed Bactrim. The decision was based on a change in mental status, but the urinalysis showed only yeast presence. The DON confirmed the resident did not meet the criteria for antibiotic initiation, indicating a lapse in policy adherence.
The facility failed to provide written notification of transfers to an acute care facility to the family and/or LTC Ombudsman for two residents. One resident with moderate cognitive impairment was transferred to the hospital without Ombudsman notification. Another resident, who was cognitively intact, experienced a change in condition and was also transferred without proper notification. Interviews confirmed the lack of evidence for written notifications, despite facility policy requiring such notices.
Expired and improperly stored medications found in carts and medication rooms
Penalty
Summary
Drugs, biologicals, and medication storage areas were not maintained in accordance with accepted professional principles. On Unit C2, a medication room contained 47 expired Ultrasite needleless connectors and 23 expired heparin flush syringes stored in an unlabeled container mixed with other supplies in the bottom drawer of a cabinet. The heparin flushes were identified by LPN #11 as intended for return to the pharmacy, but the drawer had no label or signage indicating that it was designated for pharmacy return. The same medication room refrigerator contained a tuberculin vial with the dust cover cap removed, no documented open date, and a needle puncture in the septum. The Unit C1 medication room refrigerator also contained a tuberculin vial with the dust cover cap removed, no open date documented, and a needle puncture in the septum. Additional medication storage issues were observed in multiple carts and rooms. A hallway C1 medication cart had three loose pills in the second drawer, identified as pantoprazole sodium delayed release 40 mg, gabapentin 100 mg, and fluoxetine hydrochloride 40 mg. The Unit B medication cart had three loose pills in the second drawer, identified as citalopram hydrobromide 20 mg, diclofenac sodium delayed release 50 mg, and furosemide 40 mg. The Unit A1 medication room contained expired intravenous start kits, expired Ulticare TB syringes, and expired Safety Needles. The Unit CL1 medication cart contained an expired EpiPen and an expired bisacodyl suppository, and the Unit CL1 medication room contained a tuberculin vial with an open date of 04/03/25, a needle puncture in the septum, and an expiration date of 04/2026. The facility policy required multi-use vials to be dated when first accessed and discarded within 28 days unless otherwise specified, and expired, discontinued, or deteriorated drugs or biologicals to be returned or destroyed per pharmacy guidelines.
Improper freezer food storage and ice buildup
Penalty
Summary
The facility failed to store food in a safe and sanitary manner. During an observation of the kitchen walk-in freezer, a ten pound box of breakfast sausage, a twenty pound box of burger patties, and a ten pound box of cod were found partially used and unsealed, open to the freezer air. The freezer door would not close fully because of ice buildup around the perimeter of the door frame, and ice buildup was also observed on several containers of ice cream. A Dietary Aide confirmed that the food items were opened and unsealed, that ice had built up on freezer contents and around the door frame, and that the buildup was preventing the door from shutting. The aide was observed chipping ice away from the freezer door frame with a kitchen scraper tool so the door could close. Review of the facility policy stated that food is to be stored by methods designed to prevent contamination and that foods should be covered, labeled, and dated.
Bed Equipment and Call Light Accessibility Failures
Penalty
Summary
The facility failed to provide Resident #64 with a hospital bed that worked appropriately. Resident #64 was admitted with lumbar fractures and liver cancer, was cognitively intact, and required moderate to maximum assistance with bed mobility. The care plan addressed altered skin integrity risk and included a pressure-redistributing bed surface, heel protection, and turning and repositioning. During interviews and observations, Resident #64 reported that the bed was too long for the frame and that he continuously slid down in the bed. Staff and the resident’s daughter confirmed the foot of the bed had been an ongoing concern since admission, and observations showed the foot of the bed was angled downward and would not raise to a flat position. The facility also failed to provide Resident #5 with a bed and mattress of appropriate length. Resident #5 was 77 inches tall and had diagnoses including osteoarthritis of the right hip, diabetes with foot ulcer, osteomyelitis, peripheral vascular disease, and a stage IV right heel pressure ulcer. Observation showed the mattress was 8.5 inches shorter than the bed frame, with pillows filling the gap between the mattress and frame. Resident #5 stated the bed and mattress were too short for him, that a longer bed and mattress had not been provided, and that his feet rested against the foot board, causing him to place a pillow there to avoid pain. The facility further failed to ensure the call light was within reach for Resident #55. Resident #55 had diagnoses including a lumbar fracture, fall, finger fracture, gait and mobility abnormalities, and Parkinson’s disease, and the care plan identified a fall risk with an intervention for the call light to be within reach. During observation, the call light was attached to the bed rail while the resident was seated in a recliner one to two feet away from the bed. An LPN verified the call light was out of reach, and staff stated the resident usually called out when he needed help.
Bathing Preferences Not Honored
Penalty
Summary
The facility failed to ensure Resident #93’s bathing preferences were honored. The resident was admitted with diagnoses including fracture of the upper and lower end of the right fibula and morbid obesity due to excess calories. The five-day MDS showed the resident was dependent on staff for showering or bathing, and the bathing task documentation from 12/20/25 through 03/10/26 showed only two showers, on 02/27/26 and 03/06/26, with multiple bed baths on other dates and some dates when the resident was not available. There was no documentation that Resident #93 refused showers, and the progress notes also contained no documentation of shower refusals that led to bed baths. The resident’s Kardex stated that bed baths were to be provided when a full bath was not tolerated. The resident’s daughter stated she was concerned the resident was not receiving showers as scheduled and was only receiving bed baths. A CNA stated the Kardex indicated bed baths only if a full shower was refused, while another CNA stated the resident preferred showers and the family preferred showers, but the resident was a Hoyer lift transfer and mainly received bed baths instead of showers due to the transfer with staff. The DON stated that if there was a refusal of care, the nurse should document it in the EMR, and confirmed there were no refusals documented regarding showers for Resident #93.
Failure to Provide Privacy During Blood Draw
Penalty
Summary
The facility failed to ensure privacy during a blood draw for Resident #123. Resident #123 was admitted with diagnoses including Alzheimer's disease, chronic pain syndrome, and osteoporosis, and the MDS assessment indicated severe cognitive function and wheelchair use for mobility. On 03/09/26, the resident was observed sitting in the television room with three other residents, and at 9:40 A.M. the phlebotomist performed a venipuncture from the resident's right antecubital region in the presence of other residents in the communal area. The phlebotomist confirmed the blood draw was done in the television room and stated it occurred there because the resident was initially refusing the blood draw, adding that it was not typical to perform a blood draw in a public space. The facility's Venipuncture Specimen Collection policy, issued 08/07/23, stated privacy was to be provided during venipuncture sample collection.
Failure to Provide Timely Bathing and Personal Hygiene
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for activities of daily living received adequate and timely bathing and personal hygiene. This affected three residents reviewed for ADLs. The report identified that Resident #2, who had diagnoses including hypotension, diabetes mellitus, pulmonary hypertension, muscle weakness, and chronic kidney disease, was dependent on staff for personal hygiene and bathing, yet was observed with multiple chin hairs present. The resident stated staff had not offered to shave her chin hairs, and a CNA later confirmed the facial hair and stated she would shave the resident that day after the shower. Resident #151, who had diagnoses including diabetes mellitus, fracture of the left radius, muscle weakness, osteoarthritis, tremor, and macular degeneration, was also dependent on staff for bathing and personal hygiene. During observation, the resident’s fingernails were about one inch beyond the fingertips. The resident stated the facility refused to cut her fingernails and had asked for an appointment with a manicurist. The staff bath task indicated nail length should be checked and trimmed as appropriate. The Unit Manager stated nail care should be completed at least weekly and confirmed the nails were too long and could injure the resident’s skin; she then trimmed the nails. Resident #12, who had diagnoses including surgical aftercare following digestive system surgery, retroperitoneal abscess, cirrhosis of the liver, and hydronephrosis with ureteral stricture, was cognitively intact and required extensive assistance with bathing and other ADLs. The resident’s assessment showed a preference for choosing a shower, tub bath, or sponge bath, but task documentation showed repeated bed baths with no showers documented and no refusals documented. The resident stated she was only being given bed baths and preferred showers, and her hair appeared disheveled. A CNA stated the resident typically chose bed baths, that staff used a shampoo cap during bed baths, and that the back of the resident’s hair was very matted; the CNA also stated the resident refused turning for care to the back of the head and refused trimming of the matted hair, but there was no documentation of such refusals. The DON stated refusals should be documented by nursing and that it was best practice to offer a full hair wash before using a shampoo cap.
TLSO Brace Not Applied per Physician Order
Penalty
Summary
The facility failed to ensure Resident #55’s orthotic device was in place according to physician orders. Resident #55 was admitted on 03/12/25 with diagnoses including wedge compression fracture of the first lumbar vertebra, concussion without loss of consciousness, disorder of bone density and structure, Parkinson’s disease, and anxiety disorder. The MDS showed moderate cognitive impairment and need for moderate assistance with showering and upper body dressing. The care plan identified fall risk related to decreased mobility, assistive device use, staff assistance, a recent hospital admission after a fall with closed head trauma, acute lumbar fracture managed non-operatively, and use of a TLSO brace. The physician order dated 01/07/26 directed that the lumbar sacral brace be worn at all times when sitting or standing and removed only while sleeping, with instructions not to remove it for showering. During observation, Resident #55 was found sitting in a recliner with part of the brace lying in his lap, and an LPN stated the TLSO was not on correctly and corrected it. On another observation, the resident was sitting in his room with no TLSO brace on, and the brace was sitting on top of the trash can by the recliner. The resident stated he did not take off the brace and that no one had put it on him that day. A unit manager verified the brace was on top of the trash can and stated it should be on the resident. The TAR showed the brace had been checked as applied for the morning shift.
Failure to Ensure Routine Podiatry Services
Penalty
Summary
The facility failed to ensure a resident was seen routinely for podiatry services. The resident had diagnoses including dementia and anxiety, and the quarterly MDS showed severe cognitive impairment with a need for supervision with personal hygiene and showering. The care plan included ADL support to check nail length and trim and clean nails on bath day and as needed, as well as ancillary services for needs such as podiatry. The resident also had signed consent for the facility to provide outside podiatry services. Review of the podiatry record showed the resident was seen on 07/16/25, when both feet had elongated, discolored, mycotic, thick toenails with subungual debris, and the nails were debrided and reduced in length and thickness. The podiatry recommendation was that the resident be seen as medically necessary but no sooner than 60 days. However, review of the podiatry lists for multiple dates from 08/29/25 through 01/27/26 showed the resident was not listed to be seen, and there were no podiatry notes for September 2025 through February 2026. There were also no progress notes showing podiatry services were offered and declined. Later documentation showed the resident developed a right great toe problem, including the toenail falling off, a partially detached toenail, erythema, edema, increased temperature, pain, purulent drainage, and a faint odor. The resident was treated with cleansing, dressing changes, skin prep, and Augmentin for infection. During observation on 03/11/26, the resident’s toenails were still yellow, thick, and overgrown; the second toenail on the right foot was broken in half; the left great toenail caused pain when touched; and there was brown substance under the nail. Social Services and the DON stated residents were generally seen every two to three months, but neither could provide a reason why this resident was not seen by podiatry.
Fall interventions not consistently in place for a resident at risk for falls
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident at risk for falls with a history of falls. Resident #17 was admitted with diagnoses including a displaced fracture of the base of the neck of the right femur, a history of falling, vascular dementia, Parkinson's disease, and malignant neoplasm of the bronchus or lung. The MDS assessment showed moderate cognitive impairment, lower extremity impairment on one side, dependence on staff for toileting hygiene, mobility, and transfers, and two or more falls since admission without injury. The care plan identified the resident as at risk for falls due to decreased mobility, need for staff assistance, impaired decision making, dementia, and Parkinson's disease, and included interventions for a fall mat at bedside when in bed, the bed placed against the wall, and bolsters on the bed. After the resident reported falling overnight and getting himself back up, nursing assessed him and noted his right lower extremity was rotated inward. The nursing note documented that a fall mat was placed at the bedside as an immediate intervention, and secondary interventions included moving the bed against the wall and adding bolsters. However, physician orders later reflected these interventions with an effective date of 03/04/26, and observations on 03/09/26 showed the bed centered in the room with no fall mat at the bedside. A later observation showed the bed against the wall with a fall mat present, but no bolsters were present. An LPN confirmed the bed had not been against the wall and the fall mat had not been present earlier, and also confirmed there were no bolsters on the bed.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to accurately assess and provide timely ongoing monitoring for a resident with significant weight loss. Resident #39 had diagnoses including anxiety, depression, muscle weakness, chronic respiratory failure, CHF, CKD stage III, and COPD. The initial nutrition assessment identified the resident as at risk for malnutrition related to CHF and CKD, and the RD recommended a house med pass supplement twice daily, but the recommendation was not implemented until 20 days later when the physician ordered the supplement. The resident was cognitively intact, required supervision or touching assistance with eating, and did not refuse care during the review period. The resident’s weight changed from 106 lbs. to 110.0 lbs., then to 100 lbs. during a hospital admission for a GI bleed, which represented a 9.0% severe weight loss in nine days. Hospital records described the resident as euvolemic and noted no findings of fluid overload on chest CT. After the resident returned to the facility, there was no weight obtained on readmission. The subsequent nutrition assessment addressed the hospital weight loss but attributed it to fluid-related changes, which was inconsistent with the hospital and nursing assessments. The RD discontinued a liquid protein supplement but did not initiate additional monitoring or nutritional recommendations. There were no additional weights obtained for the resident between return from the hospital and a later weight of 96.3 lbs., followed by 95.8 lbs. The resident stated staff had not discussed the weight loss with her and denied refusing to be weighed, and a CNA stated she was normally pleasant and agreeable to care. The RD stated he attempted to obtain a re-weight after the weight change but did not request additional attempts and acknowledged it would have been optimal to obtain weekly weights. The physician confirmed the prednisone and Lasix orders had not changed, and the facility policy required reweights when a resident weighing 100 lbs. or more gained or lost five pounds and identified 5.0% weight loss over one month as significant.
Incorrect Renal/Diabetic Diet Served
Penalty
Summary
The facility failed to ensure Resident #45 received the ordered renal/diabetic diet as prescribed. Resident #45 was admitted with diagnoses including acute on chronic diastolic congestive heart failure, type II diabetes mellitus with diabetic chronic kidney disease, type II diabetes mellitus with diabetic retinopathy without macular edema, and morbid obesity due to excess calorie. The five-day MDS indicated the resident was cognitively intact, received a therapeutic diet, and required supervision with meals. Physician orders dated 02/07/26 directed a renal/diabetic diet with regular texture and thin consistency. During observation and interview, Resident #45’s breakfast tray contained an egg on a biscuit, hashbrowns, oatmeal with milk, apple juice, and eight ounces of milk, although the renal diet menu ticket indicated only four ounces of milk and did not include the biscuit or hashbrowns. The resident stated she ate one bite of the hashbrowns but ate the biscuit, and CNA #149 confirmed the resident did not receive the correct renal diet. At lunch, the resident’s tray contained sweet potato fries instead of cauliflower listed on the renal diet menu, and CNA #149 again confirmed the incorrect diet was served. On the following morning, the resident received eight ounces of milk instead of the four ounces listed on the renal diet menu, and CNA #153 confirmed the discrepancy.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control procedures were followed during incontinence care for a resident who had dementia, anxiety, major depressive disorder, chronic respiratory failure with hypoxia, panic disorder, arthritis, and muscle weakness, and who was dependent on staff for toileting hygiene. The resident’s care plan indicated enhanced barrier precautions (EBP) related to a history of multidrug-resistant organisms, with staff to wear gowns and gloves during high-contact resident activities. During observation, a CNA prepared a bed bath using only two washcloths for the entire bath and incontinence care. The CNA washed the resident’s chest and armpits, then used the same washcloth to wash the peri-area, opened the washcloth on her open palm, made several swipes along the abdominal area, and washed downward in the vagina and then back upward in the vagina. The CNA then rolled the resident and used the same washcloth to wash the backside. After the resident had a bowel movement and refused the bedpan, the CNA used the non-soapy washcloth to wipe the backside and left the room to get more washcloths. The CNA did not cover the resident while leaving to get more washcloths and left the resident on her left side with the backside exposed. During interview, the CNA confirmed she should have had a different washcloth for pericare, acknowledged using the open palm with the washcloth and wiping instead of using a clean section each time, and confirmed she only had two washcloths for cleaning the entire body. The unit manager stated there were educational opportunities for the CNA for proper incontinence care. The facility policy required cleansing from front to rectum, using a separate area of the cloth or a new wipe for each stroke, and using alternate sites of the cloth with each downstroke for female perineal care. The facility also failed to ensure staff were aware to follow EBP for a resident with indwelling medical devices. A resident with cholecystitis and chronic respiratory failure was readmitted with right and left upper quadrant JP drains and a PICC line, and the care plan required EBP for the duration of the stay. Observation showed the resident had JP drains on the abdomen, but there was no EBP signage outside the room. An LPN confirmed there was no EBP signage and stated there should be signage as a reminder for staff to wear PPE for high-contact resident care activities. CDC guidance reviewed by surveyors stated EBP may be indicated for residents with wounds or indwelling medical devices, regardless of MDRO colonization status.
Antibiotics Prescribed Without Adequate Clinical Indication
Penalty
Summary
The facility failed to follow its antibiotic stewardship program and did not ensure antibiotics were prescribed only with adequate clinical indication for two residents reviewed. The report states that the facility used McGeer criteria as the basis for its antibiotic stewardship program and that infection criteria should be met before antibiotic therapy is started. The deficiency involved Resident #13, who had a history of Alzheimer’s disease, intestinal obstruction, and chronic gastrointestinal issues, and Resident #6, who had end stage renal disease and received an antibiotic after a hospital visit for a fall and acute cystitis. For Resident #13, the medical record showed chronic diarrhea and prior orders for antidiarrheal medications, including Imodium and Lomotil. On 03/03/26, an LPN contacted a CNP for diarrhea and received an order for metronidazole. The progress note stated the resident had several loose stools, no abdominal pain, and no fevers, and the CNP recommended a trial course of Flagyl. Subsequent notes monitored the antibiotic, but the record did not reflect an antibiotic time out. Interviews with staff and the CNP confirmed the antibiotic was not prescribed to treat an active infection; instead, it was intended to disrupt gut flora and re-bulk stools. The DON also stated the resident had chronic diarrhea and infection was not suspected. The facility did not provide stool culture results, and the McGeer worksheet showed the resident did not meet criteria for infection. For Resident #6, hospital records showed acute cystitis after a fall, and the resident was discharged with cephalexin. The facility order continued cephalexin for five days, but there was no evidence that a culture and sensitivity was completed in the hospital or by the facility. The McGeer worksheet stated the antibiotic was prescribed for urinary symptoms due to cystitis and did not meet McGeer criteria for infection. The ADON confirmed the antibiotic course was completed without a sensitivity to bacteria and without a confirmed infection.
Failure to Provide Dignified Communication for Resident with Language and Hearing Barriers
Penalty
Summary
A deficiency was identified when the facility failed to provide a dignified experience for a resident with communication barriers, specifically by not utilizing alternate communication methods as outlined in the resident's care plan and facility policy. The resident, who had diagnoses including Alzheimer's disease, bilateral hearing loss, and a language barrier due to primarily speaking Russian, was observed to lack access to a communication board in her room. Staff interactions with the resident were limited, with some staff not speaking to her or relying solely on hand gestures and simple English phrases, despite her care plan recommending the use of translation applications and communication aids. Interviews with staff revealed inconsistent use of translation applications, with some staff not having the app on their phones and others only using it if hand gestures were ineffective. The resident and her daughter both reported ongoing difficulties in communication, with the resident expressing frustration and stress due to her needs not being understood or met, including issues with medication administration timing and requests for assistance. The facility often relied on the resident's daughter to translate, rather than consistently using professional translation aids or services as required by policy. Review of the facility's policy confirmed that communication assistance should be provided through various aids and that family members should not be used as interpreters unless specifically requested by the resident after being offered a professional interpreter. Despite this, the facility's practice did not align with policy requirements, resulting in the resident experiencing daily struggles to communicate her needs and participate meaningfully in her care.
Significant Medication Errors in Antibiotic and Insulin Administration
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration and order entry. One resident, admitted with multiple complex diagnoses including pseudomonas infection and a history of urogenital implants, was prescribed cefepime as a continuous 24-hour IV infusion. However, upon admission, the antibiotic order was incorrectly entered as a twice-daily short infusion rather than a continuous infusion. This error persisted for several days, with the medication being administered incorrectly each shift. The discrepancy was eventually identified after the resident's infectious disease physician and family raised concerns, revealing that the facility had not followed the hospital's discharge prescription for continuous infusion. Another resident with a history of diabetes mellitus and other chronic conditions was prescribed sliding scale insulin to be administered subcutaneously before meals. Review of the medication administration record for this resident showed that insulin was administered late on 22 occasions within a single month. The scheduled times for insulin administration were not adhered to, with doses being given significantly after the prescribed times. Staff interviews indicated that some nurses believed they had a window of time for administration, and some attributed the discrepancies to delayed documentation rather than actual late administration. The facility's policies required that medications be administered and documented in real time, and that orders be accurately entered and verified by nursing staff. Despite these policies, the errors occurred due to incorrect order entry, lack of proper verification, and failure to document medication administration at the time it was given. These actions and inactions led to significant medication errors affecting two residents.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse to the Ohio Department of Health in a timely manner, affecting two residents. An altercation occurred between two residents, resulting in bruises and scratches. The incident was not reported immediately to the Administrator, and the Self-Reported Incident (SRI) was initiated approximately five hours after the event. This delay in reporting violated the facility's policy on timely reporting of abuse. Additionally, a representative of one of the residents reported incidents of staff-to-resident abuse during a care conference. The representative alleged that staff members held a resident down by the wrists and dragged another resident down the hallway. Despite these serious allegations being reported during the care conference, the Director of Nursing (DON) and Unit Manager present did not report or investigate these claims, and no SRIs were initiated for these allegations. The facility's policy on abuse requires immediate reporting of all allegations to the administration and the state survey agency. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the reported incidents. This deficiency was investigated under two complaint numbers, indicating a failure to comply with state regulations regarding abuse reporting.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of staff-to-resident physical abuse involving two residents. Resident #77, who has severe cognitive impairment and other medical conditions, was reportedly held down by the wrists by one staff member while another staff member flipped the resident back and forth to remove soiled clothing, causing the resident to scream in pain. This incident was reported by the resident's representative during a care conference attended by the Director of Nursing (DON), Unit Manager (UM) #54, and a hospice nurse. Additionally, the representative reported witnessing two staff members dragging Resident #78, who has Lewy body disease and other conditions, down the hallway by the arms while the resident screamed. Despite these reports being made during the care conference, the DON and UM #54 confirmed that no investigation was initiated, and the incidents were not reported to the Administrator. The facility's Self-Reported Incidents (SRIs) records showed no entries related to these allegations. The facility's policy on abuse, which mandates investigation and protective actions, was not followed. This deficiency was investigated under Complaint Numbers OH00162859 and OH00162858.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.89% based on 29 medication opportunities and two errors. This deficiency affected one resident, who was admitted with multiple diagnoses including cerebrovascular disease, hypertension, and type two diabetes mellitus. The errors involved the administration of medications that did not align with the physician's orders. Specifically, the resident was prescribed chewable Aspirin 81 mg and Senna-S 8.6-50 mg. However, during medication administration, an LPN administered an enteric-coated Aspirin tablet crushed in applesauce, which is contraindicated, and a Senna 8.6 mg tablet, omitting the 50 mg Docusate component. The LPN confirmed these errors, and the DON was notified. The facility's policy on medication administration emphasizes the importance of adhering to physician orders and professional standards, which was not followed in this instance.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of staffing schedules and confirmed by staff interviews. Specifically, there were no RNs scheduled on several dates, including Sundays and Saturdays, as well as a Friday when the RN unit manager was on vacation. The Director of Nursing (DON) and unit managers were unaware of the regulatory requirement for RN coverage, which has the potential to affect all 92 residents residing in the facility.
Failure to Designate Charge Nurse on Weekends and Holidays
Penalty
Summary
The facility failed to designate a licensed charge nurse for all tours of duty, specifically for the 7:00 A.M. to 7:00 P.M. shift on weekends and observed holidays. The daily staffing postings for June and July 2024 did not identify a charge nurse for these times, instead directing staff to an on-call list at the front desk. Interviews with the Director of Nursing (DON) confirmed that the nightshift supervisor acts as the charge nurse from 7:00 P.M. to 7:00 A.M., and the unit manager is the charge nurse during weekdays. However, on weekends and holidays, the on-call manager is considered the charge nurse and is only available by phone. The DON also revealed that there is no specific job description for a charge nurse, and any nurse could be considered in charge of their unit. An interview with a state tested nursing assistant (STNA) indicated that if there were concerns not addressed by the unit nurse, she would contact the unit manager directly, as she was not aware of a designated charge nurse.
Deficiencies in Flooring Maintenance and Homelike Environment
Penalty
Summary
The facility failed to maintain the flooring in good condition on the 200 hall, affecting all 25 residents residing there. Observations revealed torn, frayed, and loose carpet sections, creating potential tripping hazards. Despite identifying the issue in March 2024 and obtaining a quote for repairs in May 2024, no repairs or replacements had been completed by July 2024. The Maintenance Director confirmed that the facility was working on a staged approach, prioritizing other areas first, and had not yet planned for the full replacement or repair of the 200 hall. Additionally, the facility failed to provide a homelike environment for a resident with cognitive impairments and multiple health conditions, including hemiplegia and vascular dementia. Observations showed that the resident's clothing was hung in the shower rather than the closet, which was mostly empty and had ample space. Staff interviews confirmed uncertainty about why the clothing was not stored in the closet, and the situation was acknowledged as not providing a homelike environment. The facility's policy on maintaining a homelike environment was not adhered to, as unresolved environmental concerns were not reported to the administrator.
Failure to Provide Timely Beneficiary Notices
Penalty
Summary
The facility failed to provide timely Beneficiary Notices to a resident, affecting their awareness of Medicare/Medicaid coverage and potential liability for services not covered. The resident, who had diagnoses including congestive heart failure, subarachnoid hemorrhage, and acute respiratory failure, was admitted and discharged within a specific period. The review of the medical records showed that the Notice of Medicare Non-Coverage (NOMNC) was given with the last day of coverage specified, but the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) was not provided in a timely manner. Specifically, the SNF ABN was issued after the resident's covered days had ended, which was confirmed by staff interviews. The facility's policy on Advanced Beneficiary Notice of Non-Coverage requires that the notice be provided in advance to allow the beneficiary or their representative to make an informed decision. However, in this case, the SNF ABN was provided after the coverage had ended, and in one instance, only verbal notification was given on the last covered day. The staff confirmed these lapses during interviews, indicating a failure to adhere to the facility's policy, which mandates that the notice be delivered, signed, and a copy provided to the beneficiary with enough time for consideration.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency in a timely manner, affecting one resident. The resident, who was cognitively intact, had a range of diagnoses including pain in the left leg, morbid obesity, and anxiety disorder. On the day of the incident, the resident made an abuse allegation against a staff member, which was reported to the facility administrator by the receptionist. However, the administrator did not report the allegation to the state agency until the following day, despite the facility's abuse policy requiring immediate reporting, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury.
Failure to Develop Comprehensive Nutrition Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was at nutritional risk and had experienced significant weight loss. The resident, who had a history of severe protein calorie malnutrition and was at risk of malnutrition due to dysphagia and the need for alternative nutrition, lost 76.8 pounds in three months, equating to a 29.3% weight loss. Despite these significant changes, there was no care plan addressing the resident's nutritional status or weight loss. The clinical dietitian confirmed that the resident did not have an active nutrition care plan since a specified date, despite the facility's policy requiring a comprehensive, person-centered care plan to be developed within seven days of the completion of the required MDS assessment. The policy also mandates that care plans be revised as the resident's conditions change, which did not occur in this case.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely podiatry services to a resident, identified as Resident #67, who was admitted with diagnoses including muscle weakness, Parkinson's disease, dementia, unsteadiness on feet, and acute kidney failure. The resident, who was cognitively intact and required assistance for mobility, had requested podiatry services due to thickened, dystrophic, and painful nails, which increased the risk of infection. Despite a request for podiatry services being made at the end of April, the resident was not seen until July 10, 2024, after being rescheduled multiple times due to the podiatry group's lack of availability. Interviews with the resident and their family members revealed frustration and concerns about the lack of timely ancillary services and poor communication from the facility. The Director of Nursing confirmed that the resident did not receive timely podiatry services due to the podiatry group's poor availability, resulting in a delay of 10 weeks from the initial request. Observations noted that the resident's toenails were protruding, indicating the need for the requested podiatry care.
Inadequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate assistance during a transfer involving a sit-to-stand lift for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, Parkinson's disease, hemiplegia, unsteadiness on feet, visual disturbances, and heart failure. The resident required maximum assistance for transfers and had a physician's order for a mechanical lift with two-person assistance. However, a video recording showed that a State tested Nursing Assistant (STNA) conducted the transfer alone, almost causing the resident to hit his head on the lateral bar. Interviews with staff confirmed that the facility's policy required two staff members for such transfers, but the STNA proceeded alone due to the unavailability of other staff members. The STNA explained that the nurse was occupied with medication administration, and the other STNA was engaged in other duties. The facility's policy and the Kwikpoint safety guide both indicated that two or more caregivers are necessary for safe operation of the lift, highlighting a breach in protocol during the incident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to re-assess, monitor, and notify the physician following a significant weight loss in a resident. The resident, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, and depression, lost 22.6 pounds over six months, equating to a 16.7% weight loss. Despite documented meal intakes between 76-100%, there was no evidence of physician notification or a root cause analysis to determine the reason for the weight loss. The resident confirmed the weight loss and stated a preference for purchasing his own food due to disliking the facility's meals. Interviews with the dietitian and corporate dietitian revealed concerns about the accuracy of weight measurements and a lack of documentation regarding the weight loss. The dietitian noted that the resident refused supplements and medications that could stabilize his weight. The Director of Nursing confirmed the absence of physician notification and documentation of the weight loss, despite offering interventions that the resident declined. The resident was scheduled for discharge to an assisted living facility, where he could have more control over his eating patterns.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to manage a resident's complaints of pain, affecting one resident out of three reviewed for pain management. The resident, who had a history of dementia with agitation, anxiety disorder, and other medical conditions, was admitted with a care plan that included interventions for pain management. Despite the resident's complaints of left shoulder pain on two consecutive days, there was no documentation of any pharmacological or non-pharmacological interventions for pain relief during this period. Observations noted the resident vocalizing and grimacing, indicating discomfort, yet no caregivers addressed these pain concerns. Interviews with the resident's representative and facility staff confirmed the resident experienced pain and did not receive any pain medication during the specified time. The facility's policy on pain management emphasizes recognizing and managing residents' pain to maintain their well-being. However, the staff failed to adhere to this policy, as evidenced by the lack of pain management interventions and communication regarding the resident's non-verbal pain indicators.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to adhere to its medication administration policy, which mandates that medications be dispensed, administered, and documented for one resident at a time. During observations, it was noted that an LPN was administering medications to multiple residents simultaneously by stacking cups of pills labeled with room numbers. This practice was confirmed by the LPN, who admitted to not knowing the specific medications in each cup, although they were documented as given in the computer system. This affected several residents, including those with complex medical conditions such as chronic kidney disease, heart failure, multiple sclerosis, and cognitive impairments. Further observations revealed another LPN preparing and carrying multiple medication cups without labeling them, intending to administer them to different residents. This was done while waiting for residents to come out for breakfast, and the LPN confirmed the practice of preparing multiple cups at once. The Director of Nursing acknowledged that the facility's policy requires medications to be dispensed and documented one resident at a time. The failure to follow this policy was observed in residents with various medical conditions, including dementia, heart failure, and chronic pain syndrome.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure medications were secure from the time they were dispensed until administered, as observed during an annual survey. This deficiency was identified when medications were left unattended at the bedside of a resident diagnosed with Parkinson's disease, muscle weakness, cognitive communication deficit, dementia, depression, and anxiety. The resident, who was cognitively intact according to a recent assessment, did not have orders for self-administration of medications. Despite this, medications including carbidopa-levodopa and citalopram hydrobromide were found left at the resident's bedside. An interview with an LPN confirmed that leaving medications unattended was not part of standard nursing practice. The Director of Nursing also confirmed that medications should not be left in a resident's room unless the resident has been assessed and approved to self-medicate. The facility's policy on medication and treatment storage, dated August 2023, mandates that all medications must be kept secured in a locked compartment unless under direct supervision of the nurse administering them.
Lack of Hospice Communication Documentation
Penalty
Summary
The facility failed to ensure timely communication between hospice staff and facility staff for a resident receiving hospice care. The resident, who was admitted to hospice services, had multiple diagnoses including malignant neoplasms, chronic kidney disease, and a history of transient ischemic attack. Despite being on hospice care, there was no documentation of communication or hospice visits in the resident's medical record or the hospice communication book since the admission to hospice. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the lack of documentation. The RN acknowledged that the hospice RN visited the resident but agreed that there was no documentation to reflect any hospice visits. The DON confirmed the absence of hospice notes in both the communication book and the resident's chart, although verbal communication with hospice staff was reported. The DON had requested that the hospice notes be faxed to the facility.
Inappropriate Antibiotic Use Due to Lapse in Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate antibiotic use for a resident. The resident, who had a history of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, muscle weakness, anxiety, and diverticulitis, was admitted with a care plan that included monitoring for urinary tract infection (UTI) symptoms. Despite the absence of microorganisms in the urine culture and not meeting the criteria for a UTI requiring antibiotics, the resident was prescribed Bactrim for a UTI. The decision to start antibiotics was based on a change in mental status and increased confusion, but the urinalysis showed only yeast presence without any bacterial infection. The Director of Nursing confirmed that the resident did not meet the criteria for antibiotic initiation, as there were no additional symptoms such as fever or blood in the urine. The facility's policy required the use of specific criteria for initiating antibiotics, which were not met in this case. The resident remained on antibiotics due to transitioning to hospice care, highlighting a lapse in the facility's adherence to its antibiotic stewardship policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to an acute care facility to the family and/or long-term care Ombudsman for two residents. Resident #87, who had a moderate cognitive impairment and was her own responsible party, was transferred to the hospital and did not return. There was no documentation indicating that the Ombudsman was notified of this discharge. The facility's Administrator confirmed the lack of evidence for written notification to the Ombudsman. Similarly, Resident #51, who was cognitively intact, experienced a change in condition and was transferred to the hospital. The facility also failed to provide evidence of Ombudsman notification for this resident's discharge. Interviews with the Administrator and Director of Nursing confirmed the absence of written notifications to residents' representatives. The facility's policy required that a copy of the transfer/discharge notice be provided to the resident/representative and Ombudsman, which was not adhered to in these cases.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 833 citations issued within 25 miles in the last 12 months — including the 5 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 Dublin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dublin Post Acute | 0.9 mi | ★★★★★ | 34 | 0 |
| Friendship Village Of Dublin | 0.9 mi | ★★★★★ | 0 | 0 |
| The Sanctuary At Tuttle Crossing | 1.6 mi | ★★★★★ | 4 | 0 |
| The Convalarium Of Dublin | 2.5 mi | ★★★★★ | 21 | 0 |
| Mayfair Village Nursing Care Center | 2.6 mi | ★★★★★ | 19 | 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.