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Inspection visit

Inspection

SCOTTDALE HEALTHCARE & REHABILITATION CENTERCMS #3960356 citations on this visit
6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified about medications not being available for administration on multiple days for one of 10 residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease. Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection. The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00 a.m. and 8:00 p.m. and September 18, 2023, at 8:00 a.m. due to not being available from the pharmacy. There was no documented evidence that the physician was notified that cefuroxime axetil was not available from the pharmacy and that the cefuroxime axetil was not administered to Resident 6 twice a day for five days. Physician's order for Resident 6, dated September 14, 2023, included an order for the resident to receive 800 mg of Sevelamer HCl (used to control high blood levels of phosphorus in people with chronic kidney disease) with meals (8:00 a.m., 12:00 p.m., 5:00 p.m.) for end-stage renal failure. The MAR for Resident 6, dated September 2023, indicated that the resident did not receive Sevelamer from September 14, 2023, through September 18, 2023. There was no documented evidence that the physician was notified that the Sevelamer was not available and not administered to Resident 6 with meals September 14 through 18, 2023. Interview with the Director of Nursing on September 20, 2023, at 1:40 p.m. confirmed that there was no documented evidence that the physician was notified that the cefuroxime axetil and Sevelamer for Resident 6 were not available and not administered as ordered. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 396035 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated regarding fall precaution interventions for two of 10 residents reviewed (Residents 3, 8) Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls. A nursing note, dated August 12, 2023, at 3:41 p.m. revealed that Resident 3 was observed sitting in his wheelchair in the bathroom. Blood was noted on the floor next to his bed, on his bed sheets, and on his clothing. A laceration was observed on the resident's forehead that measured 9.0 x 0.5 centimeters (cm) as well as a skin tear on his right forearm. When asked what happened, the resident stated he was sitting on his bed and leaned over to reach for something and fell off the bed and hit his head on the floor. He then got himself up into his wheelchair and wheeled into the bathroom. The Certified Registered Nurse Practitioner (CRNP) was notified and an order was received to send the resident to the hospital. A physician's order, dated August 14, 2023, included an order for a perimeter mattress (mattress with raised edges to prevent rolling out) to decrease the risk of falling from bed. Observations on September 20, 2023, at 2:45 p.m. revealed that a perimeter mattress was on Resident 3's bed. There was no documented evidence that Resident 3's care plan regarding fall prevention was revised to reflect the use of a perimeter mattress on his bed. Interview with the RNAC (Registered Nurse Assessment Coordinator - responsible for developing and revising care plans) on September 28, 2023, at 2:52 p.m. confirmed that she was not aware that Resident 3 had a perimeter mattress ordered and the care plan should have been updated. A quarterly MDS assessment for Resident 8, dated June 25, 2023, revealed that the resident was confused, required extensive assistance with mobility, and was not ambulatory. A nursing note for Resident 8, dated August 6, 2023, indicated that on August 5, 2023, at 11:25 p.m. the resident rolled out of bed. The CRNP note for Resident 8, dated August 7, 2023, indicated that her current bed had a bolster but an additional wedge was needed for her to maintain her bed positioning. A CRNP order for Resident 8, dated August 7, 2023, included an order to add an extra bolster to the right side of her bed. There was no documented evidence that Resident 8's care plan regarding fall prevention/positioning in bed was revised to reflect the use of an extra bolster on the right side of her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Level of Harm - Minimal harm or potential for actual harm Interview with the Assistant Director of Nursing on September 20, 2023 at 12:26 p.m. confirmed that the plan of care was not updated related to the resident's additional bolster to be in use and that it should have been updated. 28 Pa. Code 211.11(d) Resident care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 10 residents reviewed (Resident 6). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease. Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection. The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00 a.m. and 8:00 p.m. and September 18, 2023, at 8:00 a.m. due to not being available from the pharmacy. There was no documented evidence that the cefuroxime axetil was administered to Resident 6 twice a day for five days as ordered by the physician. Physician's order for Resident 6, dated September 14, 2023, included an order for the resident to receive 800 mg of Sevelamer HCl (used to control high blood levels of phosphorus in people with chronic kidney disease) with meals (8:00 a.m., 12:00 p.m., 5:00 p.m.) for end-stage renal failure. The MAR for Resident 6, dated September 2023, indicated that the resident did not receive Sevelamer from September 14, 2023, through September 18, 2023. A nursing note, dated September 18, 2023, at 3:12 p.m. revealed that the Sevelamer was discontinued and the resident ordered calcium acetate as per the pharmacy's recommendation. There was no documented evidence that the Sevelamer was administered to Resident 6 with meals as ordered by the physician September 14 through 18, 2023. Interview with the Director of Nursing on September 20, 2023, at 1:40 p.m. confirmed that Resident 6 did not receive the cefuroxime axetil and Sevelamer as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to attempt new interventions for fall prevention for one of the 10 residents reviewed (Resident 3) and failed to ensure that fall prevention interventions were in place as ordered for one of 10 residents reviewed (Resident 8). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls. A nursing note, dated June 24, 2023, at 4:45 a.m. revealed that Resident 3 was found on the floor with both legs bent at the knees. He said that he was getting out of bed and slid down to his knees. He had an abrasion on the left knee measuring 4.0 x 3.0 centimeters (cm) and two abrasions noted on the right knee measuring 1.0 x 1.0 cm and 4.0 x 2.5 cm. There was no documented evidence that any new interventions were put into place to prevent falls for Resident 3. Interview with the RNAC (Registered Nurse Assessment Coordinator - responsible for developing and revising care plans) on September 28, 2023, at 2:52 p.m. confirmed that there was no evidence that any new fall interventions were put into place following the resident's fall on June 24, 2023. A quarterly MDS assessment for Resident 8, dated June 25, 2023, revealed that the resident was confused, required extensive assistance with mobility, and was not ambulatory, A nursing note for Resident 8, dated August 6, 2023, indicated that on August 5, 2023, at 11:25 p.m. the resident rolled out of bed. The Certified Registered Nurse Practitioner( CRNP- registered nurse with specialized training) note for Resident 8, dated August 7, 2023, indicated that her current bed had a bolster but an additional wedge was needed for her to maintain her bed positioning. CRNP order for Resident 8, dated August 7, 2023, included an order to add an extra bolster to the right side of her bed. Observations of Resident 8 on September 20, 2023, at 9:51 a.m. during care and at 11:28 a.m. revealed that the resident was in bed and that there was no extra bolster placed on the right side of the bed. There was a bolster noted in her room on her chair. Interview with Licensed Practical Nurse 1 on September 20, 2023, at 11:28 a.m. indicated that the resident should have the bolster in use when in bed because she tends to lean to the right. Interview with the Nursing Home Administrator on September 20, 2023, at 12:09 p.m. indicated that the bolster should have been in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 28 Pa. Code 211.12(d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that a resident's clinical record was complete and accurately documented for one of 10 residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, did not receive bathing during the review period, and received dialysis. Physician's orders, dated July 12, 2023, revealed that the resident received dialysis every Tuesday, Thursday and Saturday. A shower/bathing record, dated December 21, 2022, revealed that Resident 6 was to receive a bath/shower during the evening on non-dialysis days. Nurse aide documentation for August and September 2023 revealed no documented evidence that Resident 6 received a shower from August 1 through 14 and September 1 through September 7, 2023. Interview with Resident 6 on September 20, 2023, at 8:43 a.m. revealed that she was receiving her scheduled showers/baths. Interview with the Assistant Director of Nursing on September 20, 2023, at 4:16 p.m. confirmed that there was no documentation of Resident 6's bathing/showers during the mentioned time frames. 28 Pa. Code 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scottdale Healthcare & Rehabilitation Center 900 Porter Avenue Scottdale, PA 15683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during care for one of 10 residents reviewed (Resident 8). Residents Affected - Few Findings include: The facility policy for handwashing/hygiene, dated November 17, 2022, indicated that the use of gloves do not replace handwashing/hygiene. Hand hygiene is the final step after removing and disposing of personal protective equipment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 5, 2023, revealed that the resident was frequently incontinent of bowel and bladder and required extensive assistance of two for hygiene. Physician's orders for Resident 8, dated September 6, 2023, indicated that she had a pressure ulcer on her right and left buttocks and the wounds were to be cleaned with soap and water, apply zinc, and then apply a foam dressing three times a day and as needed. Observations of Resident 8 during hygiene and wound care on September 20, 2023, at 9:51 a.m. revealed that the resident was removed from a bedpan, she had smeared bowel on her buttocks and with gloves on Licensed Practical Nurse 1 cleaned the resident. After providing her care she removed her gloves, and without performing hand hygiene, she donned new gloves and proceeded to provide wound care to the resident's right and left buttocks. Interview with Licensed Practical Nurse 1 on September 20, 2023, at 10:11 a m. revealed that she should have washed her hands after removing her gloves. Interview with the Nursing Home Administrator on September 20, 2023, at 12:09 p.m. confirmed that Licensed Practical Nurse 1 should have washed her hands after providing hygiene care to Resident 8 and removing her gloves. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396035 If continuation sheet Page 9 of 9

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Citations

6 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the September 20, 2023 survey of SCOTTDALE HEALTHCARE & REHABILITATION CENTER?

This was a inspection survey of SCOTTDALE HEALTHCARE & REHABILITATION CENTER on September 20, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SCOTTDALE HEALTHCARE & REHABILITATION CENTER on September 20, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.