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Inspection visit

Health inspection

Goldthwaite Health & Rehab CenterCMS #6760863 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #43) of six residents reviewed for PASRR evaluation and screening. Residents Affected - Few The facility failed to refer Resident # 43 to the appropriate state designated MH/ID authority for evaluation. Resident #43 was diagnosed with a mental illness prior to admission. This failure could place residents at risk of risk of not being assessed by the local MH/ID authority and not receiving mental health services to address and prevent decline. Findings included: Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024 reflected diagnoses were, Schizoaffective Disorder, Bipolar Type (a mental health condition of both schizophrenia and bipolar disorder, that caused manic episodes, increased energy and feelings of sadness and hopelessness), Anxiety Disorder (extreme fear or worry), Metabolic Encephalopathy (a change in how your brain works due to an underlying condition), Depression (mood disorder that causes persistent feeling of sadness and loss of interest) and Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful or terrifying event). Resident #43's care plan did not address his schizoaffective disorder and PTSD. Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Section A1500 Pre-admission Screening and Resident Review (PASRR). The question Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? was coded as zero which indicated a response of no to the question. Review of Resident #43's PLI dated 10/04/2025, completed by an acute care hospital reflected a diagnosis of altered mental status and Section C - PASRR Screening C0100.Mental Illness is checked No and C0200. Intellectual Disability is checked No. Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was receiving psych services two times per month. (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: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building after an outside smoke break. The resident was walking down the hallway with his head down. Resident #43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said his intention was not to offend the surveyor. During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated prior to admission they reviewed the PL1 to determine if the resident had a MH/ID diagnosis. She said if the resident had a negative PL1 and had a MH/ID diagnosis they should have submitted a PLI. She said, I feel like we meet the needs of the residents. The resident would not get the proper care if appropriate psych services were not provided. Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a PLII, and the facility provided psych services via a contracted provider. During an interview on 3/19/2025 at 2:15 PM, the DON stated the facility reviewed previous health records and the ADM has gone to meet the resident to determine if the resident was a good fit for the facility. He stated the MDS nurse was responsible to complete and submit the PASRR evaluation. He said if a resident's PL1 screening was negative, the facility provided in-house psychiatric services via a contracted provider. Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a PLII, and the facility provided psych services via a contracted provider. He said the [NAME] from hospitals were most often negative and inaccurate. He said they met the needs of Resident #43 and placed the resident on psych services. During an interview on 3/19/2025 at 2:25 PM, the ADM stated the MDS nurse was responsible to complete and submit the PASRR evaluation. He also said they provide psychiatric services through a contracted provider. The facility's PASRR policy was requested on 3/192025 at 2:30 PM, and the facility did not have a related policy. Review of the facility's policy admission Criteria revised March 2019 reflected the following: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0645 The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. Level of Harm - Minimal harm or potential for actual harm (2) Residents Affected - Few The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified. 10. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital. 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital; and c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0645 the attending physician has certified (prior to admission) that the individual will need less than 30 days of care at the facility. 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: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for one (Resident #43) of six residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #43's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024, reflected diagnoses were Schizoaffective Disorder, Bipolar Type (a mental health condition that affects how people think/behave and causes manic episodes, increased energy and feelings of sadness and hopelessness), Anxiety Disorder (extreme fear or worry), Metabolic Encephalopathy (a change in how the brain works due to an underlying condition), Depression (mood disorder that causes persistent feeling of sadness and loss of interest) and Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful or terrifying event). No goals and interventions were documented to address and/or mitigate the triggers for Resident #43's documented PTSD diagnosis. Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Section D - Mood, reflected Resident #43 rarely felt isolated from others. Section E - Behaviors, reflected Resident #43 had no hallucinations or delusions. Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was receiving psych services two times per month. During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building after an outside smoke break. The resident was walking down the hallway with his head down. Resident #43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said his intention was not to offend the surveyor. During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated she and the DON were responsible to complete care plans for residents. She said the nursing staff who cared for a resident diagnosed with PTSD would have been aware if a resident needed a different type of care and staff reported no issues. She stated she was unaware Resident #43's triggers were not care planned. During an interview on 3/19/2025 at 2:15 PM, the DON stated he completed the initial comprehensive care plans and the MDS Nurse completed the care plan updates. He said residents who had a PTSD diagnosis were offered psych services through a contracted provider and they had made concessions for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0699 Level of Harm - Minimal harm or potential for actual harm residents who needed more 1:1 care. He said a resident's triggers would have been identified through staff interactions and then reported to him. He said, We have a few PTSD residents and have not had any specific interventions for those residents. Additionally, he stated Resident #43 did not have behaviors related to PTSD and that it should have been care planned. He said they met the needs of Resident #43 and placed the resident on psych services. Residents Affected - Few During an interview on 3/19/2025 at 2:25 PM, the ADM stated residents with a PTSD diagnosis were offered psych services. When asked how the facility identified triggers for residents with a PTSD diagnosis, he stated they have gone through trauma training. He said the DON was responsible to ensure care plans were updated with goals and interventions. When he was asked to identify negative outcomes for residents who did not receive the appropriate services, he said it was speculation and he could not answer that question. Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised in March 2022 reflected the following: Policy Statement - A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a) Includes measurable objectives and timeframes; b) Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including: (2) any specialized services to be provided as a result of PASRR recommendations; and c) Includes the resident's stated goals upon admission and desired outcomes; d) Builds on the resident's strength; and e) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0699 Reflects currently recognized standards of practice for problem areas and conditions. Level of Harm - Minimal harm or potential for actual harm 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a) Residents Affected - Few Provided by qualified persons; b) Culturally competent; and c) Trauma-informed 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for one of one kitchen reviewed for food storage and sanitation, in that: 1. The facility failed to ensure food in the walk-in refrigerator freezer were labeled and dated. 2. The facility failed to ensure food on the shelf was covered, labeled, and dated. These failures could place residents at risk of foodborne illness. Findings included: Observation of the Kitchen on 03/17/2025 at 08:45 AM during initial tour of kitchen, the walk-in refrigerator had a box of yogurt with an expiration date of 3/3/2025. Observation of the Kitchen on 3/17/2025 at 9:10 AM while conducting the initial tour of the kitchen, a shelf with apples and bananas revealed brown bananas, an open and expired pack of tortillas dated 2/20/2025; a pack of strawberry gelatin in a zip lock bag that was dated 9/24/2024; and a pack of either lemon gelatin or cake mix in an undated open bag. Interview with the DM on 3/19/2025 at 09:50 AM, she stated if residents were served expired food, they could get sick. The DM stated that it was her responsibility for daily to check for expired foods. DM stated she was implementing a new policy of labeling opened food items with a printed label that indicates date item is opened, expired, and a use by date. The DM stated her kitchen staff were trained on checking for expired food and labeling/dating opened food items. Interview with the DA on 3/19/2025 at 11:28 AM, she stated if residents were served expired food, they can get sick. The DA stated they were to check for expired food daily. The DA stated she has been trained on checking for expired food and labeling/dated opened food items. The DA stated per her training, she learned to label open food in a sealed container with the date, a use by date, her initials, and the expiration date. The DA stated that they were also not to use expired food. Interview with the [NAME] on 3/19/2025 at 11:32 AM, she stated residents could get food poisoning or sick if they received food that was expired. The [NAME] stated she checks food daily as she works. The [NAME] stated she has been trained on checking for expired food and labeling/dated opened food items. The [NAME] stated per her training, they were not to use expired food. When she opens food, it needs to be labeled with the date opened, use by date and expiration date. Observation of the refrigerator on 3/19/25 at 9:44 AM, refrigerated items that have been opened were labeled with a printed label indicating open date, use by date, and expiration date. Opened sliced cheese was wrapped in plastic wrap and labeled by handwritten open date 3-13-25 but it was missing the use by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 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 676086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldthwaite Health & Rehab Center 1207 S Reynolds St Goldthwaite, TX 76844 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the DON at 3/19/2025 at 2:15 PM he stated he stated if a resident received expired food, the potential harm was they can become sick. The DON stated it was the dietary manager responsibility to make sure expired food was discarded. The DON stated residents receiving expired food does not meet his expectation. Interview with the ADM at 3/19/2025 at 2:25 PM he stated if a resident had received expired food, the potential harm was they can become sick. The ADM stated it was the dietary manager's responsibility to make sure expired food was discarded. The ADM stated residents receiving expired food does not meet his expectation. Review on 3/19/2025 at 10:15 AM revealed Policy entitled Dietary Services Policy and Procedures Manual including Food Safety and Storage Refrigerators, revealed The facility will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in the compliance with all State, Federal, and local laws, and regulations. Food shall be managed in a safe manner. Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. Food must be covered when stored, with a date label identifying what is in the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676086 If continuation sheet Page 9 of 9

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Citations

3 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.

  • 0645GeneralS&S Dpotential for harm

    F645 - Preadmission Screening for individuals with a mental disorder and individuals

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

FAQ · About this visit

Common questions about this visit

What happened during the March 19, 2025 survey of Goldthwaite Health & Rehab Center?

This was a inspection survey of Goldthwaite Health & Rehab Center on March 19, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Goldthwaite Health & Rehab Center on March 19, 2025?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"

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.