Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maplewood Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to include individualized care plan problems, goals, and interventions for three residents receiving antiplatelet or anticoagulant medications, despite physician orders and TAR entries documenting blood‑thinner use and monitoring. Residents on clopidogrel with aspirin, apixaban, and enoxaparin had admission MDS assessments indicating antiplatelet or anticoagulant therapy, but their comprehensive care plans, Kardexes, and care guides did not identify bleeding risk or blood‑thinner use. One resident reported daily abdominal injections and bruising at the injection site. An NA stated she relies on care guides and the Kardex, which did not show blood‑thinner use, and needed to ask a nurse for this information. An LPN indicated such risks should be care planned, while the clinical care coordinator and DON either were unaware of or could not explain the need to address high‑risk medications in care plans. The facility’s care planning policy lacked specific guidance on identifying and care planning for high‑risk medications and administration routes.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of PPE during high-contact resident care activities, such as IV antibiotic administration and wound care. Additionally, hand hygiene practices were not followed, and shared equipment was not disinfected between uses. Reusable ice packs were improperly stored with resident food, violating infection control protocols.
A facility failed to clean the ceiling exhaust fan in a third-floor shower room, affecting residents using the room. Observations showed the vent was covered in gray debris, and interviews with staff revealed confusion over cleaning responsibilities. Maintenance and housekeeping staff had differing accounts of cleaning routines, and the facility lacked a clear policy or checklist for daily cleaning.
A resident with intact cognition was not included in healthcare decisions, as the facility continued to involve a family member as power of attorney without the resident's consent. Despite the resident's expressed desire to change the power of attorney, the facility did not facilitate this change or include the resident in care conferences.
A resident with diabetes, hypertension, and congestive heart failure experienced new vision loss, but the facility failed to notify the physician or schedule an urgent appointment with a retinal specialist as recommended. Despite the resident's complaints and visible eye irritation, staff did not assess or document the condition properly. The facility's policy on change in condition notification was not followed, leading to a delay in addressing the resident's vision issues.
A facility failed to include a swallow study referral in a resident's discharge plan, despite recommendations from the SLP due to dysphagia. The resident, with multiple medical conditions, was discharged without arrangements for the study, and staff interviews revealed a lack of communication and coordination. The facility's discharge planning policy was not effectively executed, leading to a deficiency in meeting the resident's post-discharge needs.
A resident with diabetes and hypertension experienced vision loss due to the facility's failure to schedule a timely appointment with a retinal specialist, despite urgent recommendations. The resident reported symptoms for weeks, but the nursing staff did not assess or document the condition, and the Health Information Manager missed the urgency in the follow-up instructions.
Two residents at the facility were not offered or provided updated pneumococcal vaccinations as per CDC guidelines. One resident, with a history of chronic conditions, had consented to additional vaccines, but there was no documentation of shared clinical decision-making. Another resident's vaccine history was unclear, and there was no follow-up on her vaccination status. The DON admitted to not reviewing vaccines per updated CDC recommendations and failing to verify the second resident's vaccine history.
A resident with intact cognition was not invited to participate in care conferences, despite being capable of making her own healthcare decisions. The facility failed to document any refusal or impracticability of her participation, leading to a deficiency in care planning. Interviews revealed a lack of communication and adherence to policies regarding resident involvement in care planning.
A facility failed to adequately assess and supervise a resident for safe smoking practices, leading to safety hazards. The resident, who used intermittent oxygen therapy, had a history of smoking incidents, but the facility did not conduct timely assessments. Additionally, the facility did not address a safety hazard involving resident-to-resident abuse, where a resident with cognitive impairment and substance use history was involved in an altercation. The facility's failure to follow policies for smoking assessments and managing resident behavior contributed to the deficiencies.
A resident with pulmonary embolism and dyspnea did not have their oxygen tubing changed weekly as required, despite documentation indicating otherwise. Observations showed the tubing was dated 9/3, and staff interviews confirmed the lapse in maintenance and documentation accuracy. The facility lacked a specific policy on oxygen tubing but expected adherence to batch orders.
A resident with moderate cognitive impairment reported being raped at the facility to a family member over the phone, which was overheard by an NA and an LPN. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on a Saturday evening, but the facility did not report it to the State Agency until the following Monday morning, exceeding the two-hour reporting requirement.
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The documentation of edema and weight monitoring was inconsistent and lacked comprehensive details, and the resident's skin evaluations and wound assessments were found to be lacking. Interviews with staff revealed that the required monitoring and documentation were not adequately performed.
Failure to Care Plan for Residents on Blood-Thinning Medications
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing the use of blood‑thinning medications for three residents receiving antiplatelet or anticoagulant therapy. For one resident with a history of stroke and dysphagia who received clopidogrel via G‑tube and aspirin via J‑tube, the admission MDS documented antiplatelet use and the Treatment Administration Record (TAR) contained physician‑ordered monitoring related to blood‑thinning medications. However, the comprehensive care plan in effect at the time of survey did not identify any problem, goal, or interventions related to blood‑thinner use, did not identify the resident as being at risk for bleeding, and did not include interventions to manage or mitigate bleeding risk. The Kardex and requested care guide also did not identify the resident’s use of blood‑thinning medications. A second resident with atrial fibrillation had an admission MDS documenting anticoagulant use and a physician’s order for apixaban twice daily. The FDA‑approved labeling for apixaban notes increased risk of serious, potentially fatal bleeding and lists signs and symptoms of blood loss. The January TAR showed physician‑ordered monitoring interventions associated with blood‑thinning medications, but the comprehensive care plan did not include any problem, goal, or interventions related to anticoagulant therapy. This resident was not identified in the care plan as being at risk for bleeding, and there were no individualized interventions addressing management or mitigation of bleeding risk. The Kardex did not identify the resident’s use of blood‑thinning medications, and the requested care guide was not provided. A third resident with an infection and inflammatory reaction due to an internal joint prosthesis of the left knee had an admission MDS documenting anticoagulant use and a physician’s order for daily enoxaparin injections. The FDA‑approved labeling for enoxaparin states it should be used with extreme caution in conditions with increased risk of hemorrhage. The January TAR again showed physician‑ordered monitoring interventions related to blood‑thinning medications, but the comprehensive care plan did not identify any problem, goal, or interventions related to anticoagulant therapy or bleeding risk. The Kardex and an undated care guide did not identify the resident’s use of blood‑thinning medications. During interview, this resident reported receiving a daily blood‑thinner injection in the abdomen and experiencing bruising at the injection site. Staff interviews revealed that NAs rely on care guides and Kardexes, which did not list blood‑thinner use, and that the nurse manager and DON were unaware or unable to explain the need to address blood‑thinning medications and associated bleeding risk in the care plans. The facility’s care planning policy lacked specific guidance requiring identification and care planning of high‑risk medications and routes, and therefore did not ensure foreseeable risks such as bleeding from blood‑thinning medications were addressed through individualized care plan interventions.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) during high-contact resident care activities. For instance, a resident with a central line did not have EBP signage or PPE available, and staff did not wear gowns during IV antibiotic administration. Another resident with a foley catheter and a history of antibiotic-resistant infections had a wound doctor who did not don a gown during wound care, despite EBP signage being present. Additionally, the facility did not ensure appropriate hand hygiene practices. A trained medication assistant changed gloves without performing hand hygiene after washing a resident's rectal area. Shared equipment, such as a Hoyer lift, was not disinfected between uses, as observed when a lift was moved from a resident's room to a spa room without being cleaned immediately. The facility also failed to store reusable ice packs separately from food in kitchen refrigerators, which is against infection control protocols. Ice packs were found touching residents' labeled food items in multiple kitchenettes, despite signage indicating the refrigerators were for resident food only. Staff interviews confirmed that ice packs should be stored in a separate medication freezer to prevent contamination.
Uncleaned Shower Room Vent in LTC Facility
Penalty
Summary
The facility failed to ensure that the ceiling exhaust fan in a multi-resident shower room on the third floor was cleaned, potentially affecting all residents using the shower room. Observations revealed that the vent was coated with gray debris, with some particles hanging off, indicating a lack of regular cleaning. Interviews with a resident, who had previously worked as a janitor, confirmed that the vent in the common shower room was in worse condition than the one in his room, which also contained dark debris. Interviews with staff, including a social worker, maintenance personnel, and housekeeping staff, highlighted a lack of clarity and responsibility regarding the cleaning of the vents. Maintenance staff indicated that vents were supposed to be cleaned monthly, while housekeeping staff claimed daily cleaning routines included dusting and cleaning vents. However, the presence of significant debris on the vent suggested these procedures were not followed. The facility was unable to provide a policy or checklist for daily cleaning, further indicating a gap in the implementation of cleaning protocols.
Failure to Respect Resident's Healthcare Decision Rights
Penalty
Summary
The facility failed to ensure a resident's right to determine their own healthcare decisions and to revoke a power of attorney. The resident, identified as R30, had intact cognition according to multiple assessments, yet the facility continued to involve a family member, FM-A, as the power of attorney for healthcare decisions without R30's consent. Despite R30's clear cognitive status and expressed desire to change the power of attorney, the facility did not facilitate this change or include R30 in care conferences. R30's medical records indicated a history of fluctuating cognitive status due to various medical conditions, including dementia, anxiety, depression, and acute illnesses like encephalopathy and diverticulitis. However, during periods of intact cognition, R30 expressed dissatisfaction with FM-A's involvement in healthcare decisions and sought to revoke FM-A's power of attorney. The facility's records lacked evidence of R30's participation in care planning or any re-evaluation of R30's decision-making capacity following acute illnesses. Interviews with R30 and facility staff revealed that R30 was not informed or invited to care conferences, and the facility continued to rely on FM-A for consent and decision-making. The social worker and director of nursing acknowledged that R30 should have been included in care conferences and decision-making processes, given her intact cognition. The facility's failure to recognize and act upon R30's expressed wishes and cognitive status led to a deficiency in respecting the resident's rights.
Failure to Notify Physician of Resident's Vision Loss
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident experiencing new vision loss. The resident, who had intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure, was noted to have adequate vision and did not wear corrective lenses according to their care plan. However, the resident reported experiencing vision loss and irritation in the right eye, which had been occurring for three weeks. Despite this, there was no documentation that the physician had been notified or that an appointment had been made until much later. The resident had a visit summary note from an eye exam indicating the need for an urgent appointment with a retinal specialist, but the appointment was scheduled weeks later. The assistant director of nursing (ADON) and other nursing staff failed to assess the resident's eye condition or document the incident properly. The ADON admitted to not documenting the incident or notifying the provider, and the licensed practical nurse (LPN) only applied more tape to the bandage without assessing the eye. The Health Information Manager (HIM) was unaware of the urgency of the follow-up appointment and scheduled it for a later date, missing the 'ASAP' instruction from the eye doctor. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The director of nursing (DON) stated that nurses were responsible for assessing new injuries or changes in condition, but this protocol was not followed. The facility's policy on notification of a change in condition was not adhered to, resulting in a delay in addressing the resident's vision issues. The resident expressed frustration over the lack of action taken by the facility, highlighting a significant deficiency in the care provided.
Failure to Include Swallow Study in Discharge Plan
Penalty
Summary
The facility failed to ensure that a swallow study referral was included in the post-discharge plan for a resident with dysphagia, among other medical conditions. The resident, identified as having intact cognition and several diagnoses including type one diabetes mellitus, dysphagia, and end-stage renal disease, was on a therapeutic diet and had active discharge planning in place. Despite the speech language pathologist's (SLP) recommendation for a swallow study due to esophageal dysphagia, the care plan did not include an intervention for the resident to make her own post-discharge appointments for the study. The SLP had evaluated and treated the resident, recommending a swallow study on 9/19/24, but the facility's records lacked documentation of whether the study was scheduled or discussed with the resident. The discharge instructions and summary form did not include arrangements for the swallow study, and the resident reported not being made aware of any such arrangements before discharge. Interviews with facility staff revealed a lack of communication and coordination regarding the scheduling of the swallow study, with various staff members assuming others were responsible for the task. The facility's discharge planning policy required coordination by the interdisciplinary team to ensure continuity of care, but this was not effectively executed in this case. The resident expressed a desire for the facility to assist in scheduling the swallow study, as she was unsure how to do it herself. The failure to include the swallow study referral in the discharge plan highlights a breakdown in communication and responsibility among the facility's staff, leading to a deficiency in meeting the resident's post-discharge needs.
Failure to Provide Timely Vision Care
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision, as evidenced by the case of a resident with intact cognition and diagnoses of type II diabetes mellitus, hypertension, and congestive heart failure. The resident's care plan indicated adequate vision and no need for corrective lenses, with an intervention to observe for changes in visual status. However, the resident's last eye exam recommended an urgent appointment with a retinal specialist, which was not promptly scheduled. The resident experienced vision loss and reported symptoms such as looking through a red fog, which had been occurring for three weeks without appropriate intervention from the facility. The assistant director of nursing (ADON) acknowledged that the resident returned from dialysis with a patch over his eye and new orders but did not consider it a cause for concern. The ADON failed to document the incident or notify the provider, and no assessment of the resident's eye was conducted by the nursing staff. Interviews with various nursing staff revealed a lack of documentation and assessment of the resident's eye condition, despite the presence of a new bandage and the resident's complaints of irritation and vision issues. The Health Information Manager (HIM) was unaware of the need for an urgent follow-up appointment and only learned of the resident's eye issues when the resident personally reported them. The HIM admitted to missing the urgency indicated in the visit summary and scheduled the specialist appointment weeks later. The facility's policy on ancillary appointments was requested but not provided, indicating a possible lack of protocol in managing such situations. The director of nursing (DON) outlined the expected procedure for handling changes in condition, which was not followed in this case.
Failure to Provide Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, identified as R5 and R20, were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC recommendations. R5, who was at increased risk due to chronic obstructive pulmonary disease, heart failure, and a history of acute respiratory failure, had received PCV-13 and PPSV23 vaccines in 2015. Although R5 consented to receive additional pneumococcal vaccines per CDC guidelines, her medical record lacked documentation of shared clinical decision-making regarding further vaccination. The Director of Nursing (DON) stated that shared clinical decision-making was not completed because R5's vaccines were considered complete according to the Minnesota Immunization Information Connection (MIIC), and the DON had not reviewed the vaccines in accordance with updated CDC recommendations. R20, who was also at increased risk due to conditions such as pulmonary embolism, dyspnea, chronic heart failure, and obstructive sleep apnea, had a vaccine consent form indicating previous receipt of PPSV23 and PCV-13, but the dates were unclear. Her immunization form showed no history of pneumococcal vaccinations, and her medical record lacked follow-up regarding the declination or administration of the vaccines. The DON acknowledged that no one had followed up to verify R20's vaccine history. The facility's policy required offering vaccines within 30 days of admission unless already vaccinated or contraindicated, and to verify immunization status if unknown, but these steps were not adequately followed for R20.
Resident Excluded from Care Conferences Despite Intact Cognition
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was invited to participate in care conferences, which is a requirement for care planning. R30, who had intact cognition and was capable of making her own decisions, was not included in care conferences, and there was no documentation indicating that she refused to attend or that her participation was not practicable. Despite having a health care directive that appointed a family member as her health care agent, R30 expressed dissatisfaction with not being included in healthcare decisions and care conferences. R30's medical records and interviews revealed that she was alert and oriented, with adequate long-term recall and fair short-term recall. She had a history of anemia, hypertension, dementia, anxiety, depression, and borderline personality disorder. Despite these conditions, R30 was capable of participating in her care planning, as evidenced by her ability to express her preferences and dissatisfaction with the current arrangement where her family member was contacted instead of her. Interviews with facility staff, including the social worker and director of nursing, indicated a lack of clarity and communication regarding R30's participation in care conferences. The social worker acknowledged that R30 should have been asked if she wanted to attend care conferences, given her intact cognition. The facility's policy stated that residents have the right to participate in their healthcare planning, but this was not adhered to in R30's case, leading to the deficiency.
Inadequate Smoking and Behavioral Assessments Lead to Safety Hazards
Penalty
Summary
The facility failed to adequately assess and supervise a resident, R15, for safe smoking practices. R15, who was cognitively intact and used intermittent oxygen therapy, had a history of smoking incidents, including lighting a cigarette in her room and dropping ash on her clothing. Despite these incidents, the facility did not conduct timely smoking assessments as required by their policy. R15's care plan indicated she was initially assessed as safe to smoke independently, but subsequent assessments revealed safety concerns, such as burn holes in her clothing and the need for a smoking apron. The facility's failure to conduct quarterly assessments and address these safety hazards contributed to the deficiency. Additionally, the facility did not adequately address a safety hazard involving resident-to-resident abuse. R50, who had moderate cognitive impairment and a history of depression and substance use, was involved in an altercation with another resident, R71, who was intoxicated and made inappropriate comments. R50, feeling threatened, used his wheelchair to confront R71, leading to a physical altercation. The facility's care plan for R50 included interventions to manage his behavior and ensure his safety, but these measures were not effectively implemented, as evidenced by the altercation and R50's continued agitation and use of a flashlight for self-defense. The facility's policies and procedures for smoking assessments and managing resident behavior were not consistently followed, leading to safety hazards for both R15 and R50. The lack of timely assessments and interventions for R15's smoking safety and R50's behavioral issues contributed to the deficiencies identified in the report. The facility's failure to act upon identified safety hazards and ensure adequate supervision and assessment of residents' needs resulted in potential risks to resident safety.
Deficiency in Oxygen Tubing Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that supplemental oxygen was properly maintained and accurately documented for a resident with intact cognition and diagnoses including pulmonary embolism and unspecified dyspnea. The resident had physician orders to monitor for skin breakdown due to oxygen tubing, follow enteric contact precautions due to C. Difficile, and maintain oxygen saturations at 88% or above with 2 liters of oxygen. The resident's medication administration record (MAR) and treatment administration record (TAR) indicated that oxygen tubing was to be changed weekly, but observations revealed that the tubing had not been changed as required, with a sticker on the tubing dated 9/3, despite documentation indicating otherwise. Interviews with staff, including a registered nurse (RN) and the assistant director of nursing (ADON), confirmed that the oxygen tubing was not changed weekly as per the orders, and the documentation in the TAR was inaccurate. The assistant director of nursing acknowledged that the staff should not have signed off on the task if it was not completed, highlighting the importance of changing the tubing for infection control. The director of nursing (DON) confirmed the lack of a specific policy on oxygen tubing but expected staff to follow batch orders and document accurately. The deficiency was identified through observations and staff interviews, revealing a lapse in following professional standards for respiratory care and documentation accuracy.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Agency (SA) within the required timeframe. The resident, who had moderate cognitive impairment and was dependent on staff for all hygiene care, mobility, and transfers, reported being raped at the facility to a family member over the phone. This report was overheard by a nursing assistant (NA) and a licensed practical nurse (LPN) who were present in the room. Despite hearing the allegation, the LPN did not report it immediately, as required by facility policy and state regulations. The incident occurred on the evening of 9/14/24, but the facility did not report it to the SA until the morning of 9/16/24, well beyond the two-hour reporting requirement. The NA assumed the LPN would report the incident, while the LPN, despite acknowledging hearing the allegation, did not take action to report it, citing being preoccupied with other duties. The Director of Nursing (DON) confirmed that both the NA and LPN were aware of the allegation on the day it occurred but failed to report it as mandated. The facility's policy clearly states that any suspected abuse must be reported immediately, not later than two hours after the suspicion arises. The administrator confirmed that the expectation and policy were not followed, as the report to the SA was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to abuse reporting protocols.
Failure to Monitor Edema and Assess Non-Pressure Related Wounds
Penalty
Summary
The facility failed to monitor edema and comprehensively assess non-pressure related wounds for a resident with multiple health conditions, including brain cancer, hypertension, and chronic ischemic heart disease, who was receiving hospice care. The resident's physician orders required nurses to chart the resident's condition every shift for edema and lung checks, but the documentation was inconsistent and lacked comprehensive details. The treatment administration records indicated the presence or absence of edema and lung sounds but did not include the extent of the edema. Additionally, the resident's weight gain of 16.2 pounds over a period was not comprehensively assessed to determine if it was nutritional or fluid-related, and there was no evidence that the weight gains were evaluated for changes in the resident's overall health status and possible disease progression. The resident's skin evaluations and wound assessments were also found to be lacking. Multiple skin inspections and wound evaluations noted various bruises, skin tears, and wounds, but the documentation often did not include specific details such as wound measurements, wound beds, drainage, odor, periwound area, wound edges, risk factors, and pain. The resident's care plan identified a risk for alteration in skin integrity but did not include interventions related to edema. The facility's policies on skin assessment and wound management were not fully adhered to, as comprehensive assessments and follow-up interventions were not consistently documented. Interviews with the facility's staff, including the Director of Nursing (DON), revealed that edema was not being specifically monitored every shift as required by the physician's order. The DON acknowledged that the documentation of edema and weight monitoring was inadequate and that the resident's care plan did not include edema management. The facility's policies on resident weight evaluation and skin assessment were not fully implemented, leading to deficiencies in the monitoring and assessment of the resident's condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maplewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Gardens | 1.1 mi | — | 0 | 0 |
| Good Samaritan Society - Maplewood | 2.9 mi | — | 2 | 0 |
| Cerenity Marian Of St Paul Llc | 4.7 mi | — | 5 | 0 |
| Cerenity Care Center White Bear Lake | 4.9 mi | — | 8 | 1 |
| Capitol View Transitional Care Center | 5.3 mi | — | 1 | 0 |
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