Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Acres Wellness & Rehabilitation during CMS and state inspections, most recent first.
Three residents were discharged without complete discharge summaries, as required information such as diagnoses, course of treatment, lab results, and final status were missing or left blank. The summaries also lacked physician signatures, and staff interviews revealed inconsistent practices in completing and documenting these records. The residents involved had complex medical needs, and while discharge planning was initiated, the official documentation did not meet regulatory requirements.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
Staff failed to apply the brakes on a mechanical lift while transferring a resident with dementia and complete trisomy 21 syndrome, who was fully dependent for mobility. Two CNAs conducted the transfer without securing the lift, contrary to facility training and procedures, placing the resident at risk during the process.
The facility failed to ensure accurate MDS assessments for three residents, omitting their fall histories despite documented incidents and care plans indicating fall risks. This oversight was attributed to incomplete information following a change in facility ownership, as acknowledged by the MDS Coordinator.
A resident experienced a delay in resolving a cable service outage grievance due to the facility's failure to follow its grievance process. The resident, recovering from knee surgery and diagnosed with major depressive disorder, was not informed of the grievance policy and the issue was not resolved for nearly two weeks. Staff interviews revealed a lack of communication and documentation, contributing to the delay.
The facility failed to maintain proper sanitation and food safety standards in its kitchen, with issues such as unsealed food containers, grease build-up, and improper food storage. Perishable items were not discarded, and food preparation areas were not kept clean. Additionally, food was not served at appropriate temperatures, and thermometers were not cleaned between uses, leading to potential food contamination.
The facility failed to administer medications correctly for two residents, including not providing Lactobacillus as ordered and improperly administering Trelegy Ellipta without following rinsing instructions. Additionally, staff did not sign off on controlled substance counts during shift changes, risking drug diversion.
The facility did not provide mandatory training on effective communication for key staff members, including the Administrator, Receptionist, LVN, and Dietary Manager. This deficiency was identified through interviews and record reviews, revealing that these employees had not completed the required training, which is essential for resident safety. The facility's policy requires documentation of competency achievements and mandatory education, but the Administrator admitted that training records were not available on-site.
The facility failed to provide required training on dementia management and abuse prevention for four staff members, including the Administrator and LVN C. The absence of training records at the facility, which are kept at the corporate office, highlights a gap in compliance with the facility's policy on mandatory education documentation.
A facility failed to document a medication order change for a resident, leading to inaccurate medical records. An LVN did not record in the Nurse's Notes when he contacted the Nurse Practitioner to change the order for Lactobacillus. The resident, with a history of constipation and irritable bowel syndrome, had discrepancies in their medication administration record. The facility's policy requires documentation of such communications, which was not followed.
A resident receiving continuous enteral feeding was found lying flat on his back, contrary to the care plan and facility policy requiring the head of the bed to be elevated at 30-45 degrees to prevent aspiration. Despite staff training and awareness, the proper positioning was not maintained, as confirmed by interviews with an LVN, a CNA, and the DON.
A facility failed to maintain accurate medical records for a resident regarding the use of a wander guard device. Despite the resident's care plan indicating the need for a wander guard due to elopement risk, there was no physician's order documented before a specified date. Interviews with the DON and the resident's physician confirmed the requirement for such an order. The resident, who had a history of falls and dementia, was observed without a wander guard and could not recall any recent attempts to leave the facility.
The facility failed to provide a privacy cover for a resident's catheter bag, compromising his dignity and potentially exposing him to infection risks. Despite the facility's policy, staff did not ensure the catheter bag was covered, leaving it visible from the hallway.
A facility failed to honor a resident's preference for having her room light on at all times, despite her diagnosis of glaucoma and repeated requests. The preference was not documented in her care plan, leading to staff, including the DON, turning off the light, which violated the resident's rights to dignity and respect.
The facility failed to conduct a PASRR Evaluation for a resident identified as positive for intellectual and developmental disabilities during pre-admission screening. Despite a meeting with the local mental health authority, the necessary request for PASRR services was not submitted to the state agency, resulting in the resident not receiving required specialized services.
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in meeting their medical and nursing needs. One resident's preference for having her room light on at all times was not documented, and another resident's PASRR services were not incorporated into her care plan. This oversight could potentially violate their rights and compromise their well-being.
The facility failed to provide appropriate respiratory and catheter care for two residents. One resident's nasal cannula was not bagged when not in use, and another resident's catheter bag was left uncovered, exposing it to potential infection risks. These deficiencies were confirmed by staff and did not align with the facility's infection control policies.
Incomplete Discharge Summaries and Missing Physician Signatures
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for three residents who were reviewed for discharge documentation. Each resident's discharge summary lacked essential information, such as a recapitulation of the resident's stay, including diagnoses, course of illness or treatment, pertinent laboratory and radiology results, and a final summary of the resident's status at the time of discharge. In several cases, sections of the discharge summary were left blank, including prognosis, special treatments or procedures, medical information, cognitive and psychosocial status, sensory and physical impairments, dental condition, and status upon discharge. Additionally, the discharge summaries were not signed by the attending physician as required. For the residents involved, the records showed that they had complex medical histories, including conditions such as upper respiratory infection, ureteral stones, obstructive uropathy, pyelonephritis, Alzheimer's dementia, chronic urinary tract infection, hydronephrosis, and post-surgical rehabilitation needs. Discharge planning was initiated upon admission, and arrangements for home health services, therapy, and follow-up with primary care providers were documented in progress notes and care plans. However, the official discharge summaries did not reflect a comprehensive account of the residents' medical status or the care provided during their stay, nor did they consistently document vaccine administration or declination. Interviews with facility staff, including nurses, the DON, and medical records personnel, revealed inconsistent practices regarding the completion and physician signature of discharge summaries. Staff reported that discharge summaries were completed by nurses at the time of discharge and were supposed to be signed by the physician, but in practice, this was not consistently done. The medical records staff also indicated that some discharge documents had not yet been scanned into the electronic medical record. Facility policies required that discharge summaries be provided to residents and included in the medical record, with specific content requirements that were not met in these cases.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Secure Mechanical Lift Brakes During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and safe transfer assistance for a resident with significant physical and cognitive impairments. During a transfer from a wheelchair to a bed using a mechanical lift, two CNAs did not secure the brakes on the lift before elevating the resident. One CNA positioned the lift and began lifting the resident without locking the brakes, while the other CNA moved the wheelchair and assisted with the transfer. Both CNAs acknowledged after the transfer that the brakes had not been applied, and recognized that this was not in accordance with safe transfer procedures. The resident involved had a history of dementia, degenerative disease of the central nervous system, and complete trisomy 21 syndrome, and was dependent on staff for all mobility and transfers. The care plan indicated the resident was normally bedfast and required two staff for transfers using a mechanical lift. Interviews with the ADON and DON confirmed that staff are trained to apply the mechanical lift brakes before lifting a resident, and that failure to do so could result in injury. The facility was unable to provide a copy of its transfer and ADL policy when requested.
Inaccurate MDS Assessments for Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the fall history of three residents, leading to a deficiency in the accuracy of resident assessments. Resident #7, a female with dementia and unsteadiness on feet, had a documented fall on January 27, 2025, which was not captured in her MDS assessment. Her care plan indicated a risk for falls due to various factors, including dementia and poor safety awareness, yet the MDS inaccurately reported no falls since admission. Similarly, Resident #8, also diagnosed with dementia and unsteadiness, had a fall on January 12, 2025, which was not reflected in her quarterly MDS. Her care plan noted a history of falls and risk factors such as confusion and poor safety awareness. Despite these documented incidents and risks, the MDS inaccurately stated that she had not experienced any falls since admission. Resident #9, a male with moderate cognitive impairment and unsteadiness, experienced a fall on January 1, 2025, resulting in a minor injury. This incident was not captured in his MDS assessment, which incorrectly indicated no falls since admission. The MDS Coordinator acknowledged the oversight, attributing it to a lack of complete information following a change in facility ownership. The Director of Nursing emphasized the importance of accurate MDS assessments for effective care planning, noting that inaccuracies could impact the interventions in place for residents.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, specifically for a resident who experienced a cable service outage. The resident, who was admitted for recovery from knee surgery and had a diagnosis of major depressive disorder, reported that the cable television channels went out the day before Christmas, leaving only one channel available. Despite voicing her complaint immediately to the staff, the issue was not resolved until nearly two weeks later. The resident was not informed of the facility's grievance policy upon admission and was not provided with any policy regarding the grievance process. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) did not complete a written grievance form, assuming the Maintenance Director was already addressing the issue. The Maintenance Director confirmed the cable outage was due to a transition of new ownership affecting payment of services. He attempted to resolve the issue but did not file a grievance, and the administration was not immediately informed. The Facility Administrator learned of the issue during a morning meeting and acknowledged that no formal grievance was filed, which contributed to the delay in resolving the issue. The facility's grievance records from November 2024 through January 2025 showed no grievance filed for the resident's concern. The Facility Administrator admitted that the grievance process was not followed, which may have delayed the resolution. The facility's grievance policy allows residents to file verbal or written grievances without fear of reprisal, but this process was not effectively communicated or executed in this instance.
Facility Fails to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The tile floors in the dry storage room were not kept free of black grease build-up, and foods were not stored in sealed containers. Additionally, food containers were found with grease build-up and food particles, and the sheet pan rack in the dry storage room was stained and dusty. Food cans were improperly stored alongside chemicals, and a 5-gallon water bottle was placed directly on the floor. In the walk-in refrigerator, food was not stored in sealed containers, and perishable items like cucumbers were found to be soft, mushy, and covered in fuzzy white surfaces. The facility also failed to keep food preparation tables and equipment free of rust, stains, and food particles. Foods in the refrigerator were not labeled or dated, and the metal shelving in the food preparation area was dusty. Spice bottles and food containers were not sealed properly and had grease build-up, and a scoop was improperly stored in a food container. The facility also failed to serve food at appropriate temperatures and did not clean the food thermometer between uses, which could lead to food contamination. The kitchen walls and equipment, such as the deep fryer and juice machine, were not kept clean, with evidence of rust, grease, and black substances. The facility's policies and procedures on food storage, sanitation, and temperature monitoring were not adhered to, as evidenced by the numerous deficiencies observed during the survey.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the failure to administer medications according to physician's orders and manufacturer's specifications. For Resident #22, the facility did not administer Lactobacillus as prescribed on a specific date. The medication was not available in the required capsule form, and the staff held the dose without proper documentation of the physician's order change. This oversight was confirmed through interviews with the staff involved, who acknowledged the lack of documentation and the failure to administer the medication as ordered. For Resident #35, the facility did not follow the manufacturer's instructions for administering Trelegy Ellipta Inhalation Aerosol Powder. The nurse administered the medication but failed to instruct the resident to rinse and spit the water after use, as required to prevent thrush. The nurse incorrectly assumed the resident had followed the instructions without verifying the action, leading to improper administration of the medication. Additionally, the facility did not ensure proper documentation and verification of controlled substances during shift changes. Several staff members, including LVNs and a Med Aide, failed to sign the Controlled Drugs - Audit Record after counting controlled substances, which is a critical step in preventing drug diversion. This lapse in procedure was acknowledged by the staff and confirmed by the Director of Nursing, who stated that staff were trained to complete these tasks accurately and promptly.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to include effective communication as mandatory training for direct care staff, affecting four out of nine staff members reviewed, including the Administrator, Receptionist, LVN C, and Dietary Manager. This deficiency was identified through interviews and record reviews conducted on 10/16/2024. The Business Office Manager confirmed that these employees had not completed the required training on effective communication, which is crucial for ensuring resident safety. The facility's policy on Competency and Mandatory Education Requirements, dated 09/17/2024, mandates that competency achievements and mandatory education requirements be documented and reviewed as part of the performance appraisal process. However, the Administrator acknowledged that the facility did not have copies of the training records and employee files on-site, as they were kept at the corporate office.
Deficiency in Staff Training on Dementia and Abuse Prevention
Penalty
Summary
The facility failed to provide necessary training on dementia management and resident abuse prevention for four employees, including the Administrator, Receptionist, LVN C, and Dietary Manager. This deficiency was identified during an interview and record review conducted on 10/16/2024. The Business Office Manager confirmed that these employees had not completed the required training, which is crucial for ensuring the safety and proper care of residents with dementia. The lack of training could lead to improper management of dementia-related issues among residents. The Administrator acknowledged the absence of training records and employee files at the facility, stating that these documents were maintained at the corporate office. Despite the facility's policy requiring documentation of competency achievements and mandatory education as part of the performance appraisal process, the necessary training records were not available for review. This oversight in maintaining and documenting training compliance highlights a significant gap in the facility's adherence to its own policies and procedures.
Failure to Document Medication Order Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a medication order change. A Licensed Vocational Nurse (LVN) did not document in the Nurse's Notes when he contacted the Nurse Practitioner to change the order for Lactobacillus for a resident. This lack of documentation was identified during a review of the resident's medical records, which showed discrepancies in the medication administration record and the physician's orders. The resident, a 62-year-old male, was admitted with diagnoses including constipation and irritable bowel syndrome with diarrhea. The resident's care plan noted constipation related to decreased mobility. The LVN documented a code indicating to see the Nurse's Notes on the Medication Administration Record but failed to record the communication with the Nurse Practitioner in the electronic record. This oversight was contrary to the facility's policy, which requires licensed staff to document such communications. The Director of Nursing confirmed that staff were trained to document changes in physician's orders in a timely manner.
Failure to Maintain Proper Positioning for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was properly positioned to prevent complications such as aspiration. Resident #7, a male with severe cognitive impairment and multiple medical conditions including anoxic brain damage and Parkinson's disease, was observed lying flat on his back while receiving continuous enteral feeding. This was contrary to the care plan and facility policy, which required the head of the bed to be elevated at 30-45 degrees during feeding to prevent aspiration. Interviews with staff, including an LVN and a CNA, revealed that they were aware of the requirement to maintain the head of the bed at 30 degrees for residents on continuous enteral feeding. Despite receiving monthly training on proper positioning, the staff failed to ensure Resident #7 was positioned correctly. The Director of Nursing confirmed that all CNAs and nurses were responsible for maintaining proper positioning during their rounds, which were conducted at least every two hours. The facility's policy also reflected the need for the head of the bed to be elevated during feeding, yet this protocol was not followed in the case of Resident #7.
Inaccurate Documentation of Wander Guard Use
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a wander guard device. The resident, who had a history of falls, dementia, and was at risk of elopement, was admitted and re-admitted to the facility. Despite the resident's care plan indicating the use of a wander guard to manage elopement risk, there was no physician's order documented for the device before a specified date. This lack of documentation was confirmed during interviews with the Director of Nursing (DON) and the resident's physician, who stated that a physician's order is required for the use of a wander guard. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The facility's policies on nursing documentation and physician orders did not address the accuracy of documentation, and no additional policies were provided during the survey. The resident was observed without a wander guard, and during an interview, the resident could not recall any recent attempts to leave the facility. The failure to document the physician's order for the wander guard could lead to inaccurate medical records, potentially affecting the monitoring and medical services provided to the resident.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to treat Resident #7 with respect and dignity by not providing a privacy cover for his catheter bag. Resident #7, a male diagnosed with Neurogenic Bladder and requiring a long-term Foley catheter, was observed with his catheter bag exposed and filled with dark yellow urine. The catheter bag was visible from the hallway as the resident's room door was open. This observation was confirmed by LVN A, who acknowledged the lack of privacy and the potential risks of embarrassment and infection for the resident. Interviews with the Nurse Manager, DON, and CNA B confirmed that it is the facility's policy to cover catheter bags with a privacy bag to protect residents' dignity and prevent infection. The facility's policy on catheter care also mandates that catheter bags should be covered when visible from the door or hallway. Despite this policy, the staff failed to ensure that Resident #7's catheter bag was covered, compromising his dignity and potentially exposing him to infection risks.
Failure to Honor Resident's Preference for Room Lighting
Penalty
Summary
The facility failed to ensure that a resident's preference for having her room light on at all times was honored. The resident, who has a diagnosis of glaucoma among other medical conditions, had expressed her need for the room light to remain on due to her vision impairment. Despite this, the facility did not include this preference in her care plan, and the Director of Nursing (DON) was reported to have turned off the light on multiple occasions, contrary to the resident's wishes and her family's requests. Interviews with various staff members, including a family member, a medical assistant (MA), licensed vocational nurses (LVNs), and the MDS Coordinator, confirmed that the resident's preference for having the room light on was well-known among the staff. However, it was not documented in her care plan, which could lead to staff inadvertently turning off the light, thereby not honoring her preference. The staff acknowledged that this oversight could be a risk to the resident's rights and preferences. The facility's failure to document and honor the resident's preference for having the room light on at all times is a violation of her rights to dignity and respect. The facility's own policies on resident rights emphasize the importance of treating residents with dignity and respecting their preferences. The lack of a care plan addressing this specific need highlights a significant gap in the facility's adherence to these policies.
Failure to Conduct PASRR Evaluation
Penalty
Summary
The facility failed to coordinate assessments and conduct a PASRR Evaluation for a resident who was identified as positive for intellectual disability and developmental disability during the pre-admission screening. The resident was admitted to the facility without a follow-up PASRR Level 2 Evaluation, which is required to determine the need for specialized services. Despite the initial screening indicating the need for further evaluation, the facility did not complete the necessary steps to ensure the resident received appropriate care and services as mandated by the PASRR program under Medicaid. Interviews with facility staff, including the MDS Coordinator, Social Worker, and Director of Rehab, revealed a lack of clarity and responsibility regarding the PASRR process. The MDS Coordinator was unaware of the PASRR services and deferred to the Director of Rehab and Social Worker, who both acknowledged that a meeting was held with the local mental health authority. However, they did not submit the request for PASRR services to the state agency, mistakenly believing the resident was already receiving these services in the community. This misunderstanding led to the failure to conduct the required PASRR Evaluation. Further interviews with representatives from the local mental health authority confirmed that the resident was not receiving PASRR services in the community and required these services. The facility's failure to conduct the PASRR Evaluation and submit the request for services to the state agency resulted in the resident not receiving the necessary specialized services. This oversight was contrary to the facility's policy and the requirements of the PASRR process, which aims to ensure that individuals with intellectual disabilities receive appropriate care in the most suitable setting.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their medical and nursing needs. Resident #4, who has a history of glaucoma and other medical conditions, preferred to have her room light on at all times. Despite this preference being communicated to the staff, it was not included in her care plan. Multiple staff members, including the family member, MA, LVN, and MDS Coordinator, confirmed that Resident #4's preference for having the room light on was known but not documented in her care plan. This oversight could potentially violate her rights and preferences, as well as pose a risk to her well-being. Resident #6, who has a diagnosis of mental retardation and other medical conditions, was identified as PASRR positive, indicating the need for specialized services. However, the facility failed to incorporate these PASRR services into her care plan. The MDS Coordinator acknowledged that the PASRR services were discussed in a care conference but were not documented in the care plan. This failure could result in Resident #6 not receiving the necessary PASRR services, which are crucial for her care and well-being. The facility's policies on comprehensive care and PASRR services emphasize the importance of developing person-centered care plans that include measurable objectives and timetables. However, the facility did not adhere to these policies for Residents #4 and #6. The lack of proper documentation and implementation of care plans for these residents highlights a significant deficiency in the facility's ability to meet the individualized needs of its residents, potentially compromising their highest practicable physical, mental, and psychosocial well-being.
Failure to Ensure Proper Respiratory and Catheter Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received appropriate and safe care, consistent with professional standards of practice. Resident #2, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and a history of COVID-19, was observed multiple times with her nasal cannula not placed in a plastic bag when not in use. This was confirmed by the Nurse Manager and the Director of Nursing (DON), who both acknowledged that the nasal cannula should be bagged to prevent infection. Despite the resident not showing signs of respiratory distress, the improper handling of the nasal cannula posed a risk of infection. Resident #7, diagnosed with Neurogenic Bladder and using a long-term Foley catheter, was observed with his catheter bag exposed and not covered with a privacy bag. The catheter bag, filled with dark yellow urine, was visible from the hallway, compromising the resident's privacy and potentially increasing the risk of infection. This observation was confirmed by LVN A, the Nurse Manager, and the DON, all of whom stated that the catheter bag should be covered with a privacy bag to ensure sanitation and prevent bacterial contamination. The facility's policies on catheter care and infection prevention were not followed, as evidenced by the observations and interviews. The failure to properly bag the nasal cannula and cover the catheter bag exposed the residents to potential health risks and did not align with the facility's established protocols for infection control and resident privacy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 315 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Bartlett Skilled Nursing And Assisted Living | 0.6 mi | ★★★★★ | 11 | 0 |
| Franklin Heights Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 9 | 0 |
| The Montevista At Coronado | 2.5 mi | — | 0 | 0 |
| Avir At El Paso | 2.9 mi | ★★★★★ | 2 | 0 |
| Mountain View Health & Rehabilitation | 5.2 mi | ★★★★★ | 31 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for White Acres Wellness & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.