The Vardell Report.Four Seasons Healthcare & Wellness Center, LP

Across 40 inspections from October 2023 to August 2026, state surveyors documented 157 findings at Four Seasons Healthcare & Wellness Center, LP; 155 have a recorded correction and 2 await one; CMS lists 2 enforcement actions in the window.

Inspections

40

2023–2026, complaint and standard

Findings

157

Deficiencies cited by state inspectors

Corrected

155

Of 157 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 202026

   Complaint investigation

   1 finding

   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jul 312026

   Standard health inspection

   27 findings

   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Aug 20, 2026
   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Aug 20, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Aug 20, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Aug 20, 2026
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Aug 20, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jul 72026

   Complaint investigation

   2 findings

   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 18, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Jul 18, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jun 302026

   Complaint investigation

   4 findings

   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 22, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. May 262026

   Complaint investigation

   1 finding

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 5, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Mar 262026

   Complaint investigation

   1 finding

   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 3, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Feb 202026

   Complaint investigation

   3 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Mar 6, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 5, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 5, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Feb 112026

   Complaint investigation

   4 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Mar 2, 2026
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Mar 2, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 2, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 2, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Jan 92026

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jan 30, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Dec 232025

    Complaint investigation

    1 finding

    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jan 12, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Dec 122025

    Complaint investigation

    1 finding

    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Dec 24, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Dec 42025

    Complaint investigation

    1 finding

    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 11, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. Dec 22025

    Complaint investigation

    1 finding

    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Jan 17, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

14. Nov 132025

    Complaint investigation

    2 findings

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Nov 21, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 21, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

15. Oct 242025

    Complaint investigation

    2 findings

    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Oct 31, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

16. Sep 152025

    Complaint investigation

    1 finding

    • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Sep 25, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

17. Aug 222025

    Complaint investigation

    2 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 15, 2025
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Sep 15, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

18. Jul 22025

    Complaint investigation

    1 finding

    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 15, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

19. Jun 132025

    Complaint investigation

    1 finding

    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 27, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

20. Jun 112025

    Complaint investigation

    2 findings

    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 30, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 30, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

21. Apr 252025

    Standard health inspection

    31 findings

    The same visit included a complaint investigation.

    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 16, 2025
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected May 16, 2025
    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 16, 2025
    • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected May 16, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

22. Apr 32025

    Complaint investigation

    2 findings

    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 22, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

23. Mar 132025

    Complaint investigation

    6 findings

    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 4, 2025
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 4, 2025
    • F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Level DNo actual harm, potential for moreCorrected Apr 4, 2025
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 4, 2025
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 4, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

24. Feb 112025

    Complaint investigation

    1 finding

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Feb 28, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

25. Jan 132025

    Complaint investigation

    2 findings

    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Feb 3, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 3, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

26. Dec 122024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 16, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

27. Nov 282024

    Complaint investigation

    1 finding

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 18, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

28. Nov 122024

    Complaint investigation

    1 finding

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Nov 22, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

29. Oct 82024

    Complaint investigation

    2 findings

    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Oct 31, 2024
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Oct 31, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

30. Sep 122024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 30, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

31. Jul 292024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 14, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

32. Jul 112024

    Complaint investigation

    1 finding

    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Aug 5, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

33. Jun 262024

    Complaint investigation

    1 finding

    • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level ENo actual harm, potential for moreCorrected Jul 23, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

34. May 92024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 25, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

35. May 32024

    Standard health inspection

    34 findings

    The same visit included a complaint investigation.

    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected May 30, 2024
    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected May 30, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected May 30, 2024
    • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level BPotential for minimal harmCorrected May 30, 2024
    • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected May 30, 2024

    Enforcement Action

    Civil money penalty, $35,783 imposed May 3, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 3, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $27,706 imposed November 12, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 3, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

36. Apr 112024

    Complaint investigation

    1 finding

    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 29, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

37. Mar 42024

    Complaint investigation

    4 findings

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 18, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 18, 2024
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 18, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 18, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

38. Jan 122024

    Complaint investigation

    1 finding

    • F675Honor each resident's preferences, choices, values and beliefs.Level DNo actual harm, potential for moreCorrected Jan 29, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

39. Nov 272023

    Complaint investigation

    2 findings

    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 6, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

40. Oct 92023

    Complaint investigation

    4 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Nov 2, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Nov 2, 2023
    • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Nov 2, 2023
    • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Nov 2, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Medical Records, Cited in 15 Inspections

   Inspectors cited F842 in March 2024, May 2024, October 2024, January 2025, March 2025, April 2025, April 2025, June 2025, October 2025, December 2025, December 2025, February 2026, March 2026, July 2026 and July 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F842 across all 40 inspections, oldest to newest
2. 2

   Care Plans, Cited in Eight Inspections

   Inspectors cited F656 in November 2023, May 2024, October 2024, March 2025, April 2025, April 2025, February 2026 and July 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F656 across all 40 inspections, oldest to newest
3. 3

   Infection Control, Cited in Eight Inspections

   Inspectors cited F880 in March 2024, May 2024, May 2024, July 2024, April 2025, February 2026, June 2026 and July 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F880 across all 40 inspections, oldest to newest
4. 4

   Accident Hazards and Supervision, Cited in Seven Inspections

   Inspectors cited F689 in October 2023, May 2024, September 2024, April 2025, June 2025, November 2025 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F689 across all 40 inspections, oldest to newest
5. 5

   Pharmacy Services, Cited in Six Inspections

   Inspectors cited F755 in March 2025, April 2025, June 2025, February 2026, May 2026 and July 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F755 across all 40 inspections, oldest to newest
6. 6

   Needs and Preferences, Cited in Five Inspections

   Inspectors cited F558 in May 2024, April 2025, November 2025, June 2026 and July 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F558 across all 40 inspections, oldest to newest
7. 7

   Dignity and Resident Rights, Cited in Four Inspections

   Inspectors cited F550 in March 2025, April 2025, July 2025 and July 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F550 across all 40 inspections, oldest to newest
8. 8

   Telling Families About Changes, Cited in Four Inspections

   Inspectors cited F580 in April 2024, May 2024, October 2025 and July 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F580 across all 40 inspections, oldest to newest
9. 9

   Protection From Abuse and Neglect, Cited in Four Inspections

   Inspectors cited F600 in October 2023, November 2024, November 2024 and January 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242424242424242425252525252525252525252525252525262626262626262626F600 across all 40 inspections, oldest to newest
10. 10

    Citation F604, Cited in Four Inspections

    Inspectors cited F604 in May 2024, April 2025, February 2026 and July 2026. The agency describes it this way: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F604 across all 40 inspections, oldest to newest
11. 11

    Quality of Care, Cited in Four Inspections

    Inspectors cited F684 in December 2024, January 2025, August 2025 and February 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F684 across all 40 inspections, oldest to newest
12. 12

    A Clean, Homelike Setting, Cited in Three Inspections

    Inspectors cited F584 in May 2024, December 2025 and December 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F584 across all 40 inspections, oldest to newest
13. 13

    Pressure Injury Care, Cited in Three Inspections

    Inspectors cited F686 in May 2024, February 2025 and February 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F686 across all 40 inspections, oldest to newest
14. 14

    Respiratory Care, Cited in Three Inspections

    Inspectors cited F695 in March 2024, April 2025 and July 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F695 across all 40 inspections, oldest to newest
15. 15

    Medication Error Rate, Cited in Three Inspections

    Inspectors cited F759 in May 2024, April 2025 and July 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F759 across all 40 inspections, oldest to newest
16. 16

    Significant Medication Errors, Cited in Three Inspections

    Inspectors cited F760 in May 2024, April 2025 and August 2025. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F760 across all 40 inspections, oldest to newest
17. 17

    Food Quality and Temperature, Cited in Three Inspections

    Inspectors cited F804 in May 2024, April 2025 and July 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F804 across all 40 inspections, oldest to newest
18. 18

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in May 2024, April 2025 and July 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F812 across all 40 inspections, oldest to newest
19. 19

    Antibiotic Use, Cited in Three Inspections

    Inspectors cited F881 in May 2024, April 2025 and July 2026. This citation covers the home’s program for monitoring antibiotic use. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F881 across all 40 inspections, oldest to newest
20. 20

    Treatment Choices and Advance Directives, Cited in Two Inspections

    Inspectors cited F578 in May 2024 and July 2024. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F578 across all 40 inspections, oldest to newest
21. 21

    Grievances, Cited in Two Inspections

    Inspectors cited F585 in May 2024 and April 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F585 across all 40 inspections, oldest to newest
22. 22

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in May 2024 and July 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F657 across all 40 inspections, oldest to newest
23. 23

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in November 2023 and March 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F677 across all 40 inspections, oldest to newest
24. 24

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in May 2024 and June 2024. The agency describes it this way: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F693 across all 40 inspections, oldest to newest
25. 25

    Citation F694, Cited in Two Inspections

    Inspectors cited F694 in May 2024 and April 2025. The agency describes it this way: Provide for the safe, appropriate administration of IV fluids for a resident when needed. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F694 across all 40 inspections, oldest to newest
26. 26

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in May 2024 and April 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F758 across all 40 inspections, oldest to newest
27. 27

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in May 2024 and April 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F761 across all 40 inspections, oldest to newest
28. 28

    Citation F802, Cited in Two Inspections

    Inspectors cited F802 in May 2024 and April 2025. The agency describes it this way: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F802 across all 40 inspections, oldest to newest
29. 29

    Citation F803, Cited in Two Inspections

    Inspectors cited F803 in May 2024 and April 2025. The agency describes it this way: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F803 across all 40 inspections, oldest to newest
30. 30

    Citation F806, Cited in Two Inspections

    Inspectors cited F806 in May 2024 and July 2026. The agency describes it this way: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F806 across all 40 inspections, oldest to newest
31. 31

    Garbage and Refuse, Cited in Two Inspections

    Inspectors cited F814 in May 2024 and July 2026. This citation covers whether garbage and refuse are disposed of properly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F814 across all 40 inspections, oldest to newest
32. 32

    Professional Standards, No Recorded Correction

    F658 was cited in May 2024, April 2025 and July 2026. This citation covers whether the home’s services meet professional standards of quality. The most serious was level E (no actual harm, potential for more). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F658 across all 40 inspections, oldest to newest
33. 33

    Continence and Catheter Care, No Recorded Correction

    F690 was cited in May 2024, April 2025, July 2026 and August 2026. This citation covers continence care, catheter care and preventing urinary tract infections. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    23232424242424242424242424242425252525252525252525252525252525262626262626262626F690 across all 40 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How can a family request a resident’s records, and how are they kept accurate?

   Medical Records: cited in 15 inspections, most seriously at level E.

2. 02

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in eight inspections, most seriously at level E.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in eight inspections, most seriously at level E.

4. 04

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in seven inspections, most seriously at level J.

5. 05

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in six inspections, most seriously at level E.

6. 06

   How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

   Needs and Preferences: cited in five inspections, most seriously at level E.

7. 07

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in four inspections, most seriously at level E.

8. 08

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in four inspections, most seriously at level E.

9. 09

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in four inspections, most seriously at level J.

10. 10

    What changed after F604 was cited, and how do you check it now?

    Citation F604: cited in four inspections, most seriously at level E.

11. 11

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in four inspections, most seriously at level E.

12. 12

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in three inspections, most seriously at level D.

13. 13

    How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

    Pressure Injury Care: cited in three inspections, most seriously at level E.

14. 14

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in three inspections, most seriously at level E.

15. 15

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in three inspections, most seriously at level E.

16. 16

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in three inspections, most seriously at level E.

17. 17

    May we try a meal, and how do you check food temperature by the time it reaches residents?

    Food Quality and Temperature: cited in three inspections, most seriously at level E.

18. 18

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level E.

19. 19

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in three inspections, most seriously at level E.

20. 20

    How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

    Treatment Choices and Advance Directives: cited in two inspections, most seriously at level E.

21. 21

    How do we file a grievance, who answers it, and how quickly?

    Grievances: cited in two inspections, most seriously at level E.

22. 22

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level D.

23. 23

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level D.

24. 24

    What changed after F693 was cited, and how do you check it now?

    Citation F693: cited in two inspections, most seriously at level E.

25. 25

    What changed after F694 was cited, and how do you check it now?

    Citation F694: cited in two inspections, most seriously at level D.

26. 26

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

27. 27

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

28. 28

    What changed after F802 was cited, and how do you check it now?

    Citation F802: cited in two inspections, most seriously at level E.

29. 29

    What changed after F803 was cited, and how do you check it now?

    Citation F803: cited in two inspections, most seriously at level E.

30. 30

    What changed after F806 was cited, and how do you check it now?

    Citation F806: cited in two inspections, most seriously at level D.

31. 31

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in two inspections, most seriously at level F.

32. 32

    How do you check that nurses and aides follow professional standards, and what happens when they do not?

    Professional Standards: cited in three inspections, most seriously at level E. The July 31, 2026 citation has no recorded correction date.

33. 33

    How is continence care scheduled, and how do you prevent urinary infections?

    Continence and Catheter Care: cited in four inspections, most seriously at level E. The August 20, 2026 citation has no recorded correction date.

34. 34

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

35. 35

    What led to the 2024 fine, and has it been paid?

    A $27,706 civil money penalty was imposed November 12, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Oct 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Nov 27, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jun 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Sep 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Oct 8, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Nov 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Nov 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Dec 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jun 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jun 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Aug 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Sep 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Oct 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Nov 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Dec 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Dec 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Dec 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Dec 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 20, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jun 30, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 31, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Aug 20, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 055932

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.