The Vardell Report.Maclay Healthcare Center

Across 31 inspections from October 2023 to July 2026, state surveyors documented 168 findings at Maclay Healthcare Center; 168 have a recorded correction; CMS lists 11 enforcement actions in the window.

Inspections

31

2023–2026, complaint and standard

Findings

168

Deficiencies cited by state inspectors

Corrected

168

Of 168 findings, with a recorded correction date

Penalties

11

7 fines; payment not published, 4 closed

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. Jul 212026

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 12, 2026

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

2. Jun 92026

   Complaint investigation

   3 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 29, 2026
   • 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 DNo actual harm, potential for moreCorrected Jun 29, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 29, 2026

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

3. Apr 292026

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 26, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 2, 2026
   • 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 3, 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 Jul 2, 2026

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

4. Apr 142026

   Complaint investigation

   5 findings

   • 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 Apr 24, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 24, 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 Apr 24, 2026
   • 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 Apr 24, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Apr 24, 2026

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

5. Mar 32026

   Complaint investigation

   3 findings

   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Mar 27, 2026
   • 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 Mar 27, 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 27, 2026

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

6. Jan 162026

   Standard health inspection

   34 findings

   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level KImmediate jeopardyCorrected Feb 12, 2026
   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level ENo actual harm, potential for moreCorrected Feb 12, 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 Feb 12, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 Feb 12, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
   • 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 Feb 12, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 ENo actual harm, potential for moreCorrected Feb 12, 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 Feb 12, 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 Feb 12, 2026
   • 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 12, 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 ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
   • 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 Feb 12, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 Feb 12, 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 Feb 12, 2026
   • 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 Feb 12, 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 Feb 12, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 Feb 12, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • 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 Feb 12, 2026
   • 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 DNo actual harm, potential for moreCorrected Feb 12, 2026

   Enforcement Action

   Civil money penalty, $44,450 imposed January 16, 2026. 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 January 16, 2026, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed January 16, 2026. Status: Closed, March 27, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 16, 2026, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $12,747 imposed April 29, 2026. 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 January 16, 2026, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $22,895 imposed July 21, 2026. 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 January 16, 2026, the nearest before the penalty date.

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

7. Sep 152025

   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 Oct 15, 2025

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

8. Aug 282025

   Complaint investigation

   2 findings

   • 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 Sep 19, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 19, 2025

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

9. Jul 92025

   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 Aug 12, 2025

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

10. Jun 32025

    Complaint investigation

    4 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 Jun 27, 2025
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jun 27, 2025
    • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Jun 27, 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 Jun 27, 2025

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

11. Apr 282025

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 9, 2025

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

12. Mar 222025

    Complaint investigation

    7 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Apr 18, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Apr 18, 2025
    • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Apr 18, 2025
    • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected Apr 18, 2025
    • 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 Apr 18, 2025
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 18, 2025
    • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Apr 18, 2025

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

13. Jan 282025

    Complaint investigation

    2 findings

    • 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 Feb 12, 2025
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 12, 2025

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

14. Jan 162025

    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 Feb 4, 2025

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

15. Dec 242024

    Complaint investigation

    5 findings

    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Jan 9, 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 Jan 9, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jan 9, 2025

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

16. Dec 182024

    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 Dec 30, 2024

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

17. Oct 312024

    Complaint investigation

    2 findings

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 11, 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 Nov 11, 2024

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

18. Oct 242024

    Complaint investigation

    2 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Nov 8, 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 ENo actual harm, potential for moreCorrected Nov 8, 2024

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

19. Oct 112024

    Standard health inspection

    30 findings

    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level JImmediate jeopardyCorrected Nov 18, 2024
    • 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 Nov 18, 2024
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Nov 18, 2024
    • 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 Nov 18, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Nov 18, 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 Nov 18, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • 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 Dec 6, 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 Nov 18, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • 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 Nov 18, 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 Nov 18, 2024
    • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • 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 ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
    • 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 Nov 18, 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 DNo actual harm, potential for moreCorrected Nov 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 Nov 18, 2024
    • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Nov 18, 2024

    Enforcement Action

    Civil money penalty, $17,660 imposed October 11, 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 October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $112,506 imposed October 11, 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 October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed October 11, 2024. Status: Closed, December 6, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $52,142 imposed March 22, 2025. 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 October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 22, 2025. Status: Closed, May 9, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.

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

20. Sep 102024

    Complaint investigation

    2 findings

    • 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 Sep 26, 2024
    • F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Level DNo actual harm, potential for moreCorrected Sep 26, 2024

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

21. Aug 212024

    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 Sep 16, 2024

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

22. Aug 52024

    Complaint investigation

    4 findings

    • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Sep 23, 2024
    • 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 Aug 29, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 23, 2024

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

23. Jul 182024

    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 Aug 20, 2024

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

24. Jun 72024

    Complaint investigation

    10 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Jul 15, 2024
    • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
    • 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 ENo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
    • 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 Jul 15, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
    • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level CPotential for minimal harmCorrected Jul 15, 2024

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

25. Apr 102024

    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 27, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 27, 2024

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

26. Feb 232024

    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 Mar 6, 2024

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

27. Jan 252024

    Complaint investigation

    6 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 16, 2024
    • 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 Feb 16, 2024
    • 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 Feb 16, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 16, 2024
    • 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 Feb 16, 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 Feb 16, 2024

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

28. Dec 42023

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Dec 24, 2023

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

29. Nov 142023

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 14, 2023

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

30. Oct 252023

    Complaint investigation

    1 finding

    • 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 Nov 15, 2023

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

31. Oct 62023

    Standard health inspection

    29 findings

    The same visit included a complaint investigation.

    • 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 Oct 30, 2023
    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Oct 30, 2023
    • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 ENo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • 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 Oct 30, 2023
    • 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 ENo actual harm, potential for moreCorrected Oct 30, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 30, 2023
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Oct 30, 2023
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • 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 Oct 30, 2023
    • 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 Oct 30, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 Oct 30, 2023
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 DNo actual harm, potential for moreCorrected Oct 30, 2023
    • 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 DNo actual harm, potential for moreCorrected Oct 30, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Oct 30, 2023

    Enforcement Action

    Civil money penalty, $86,623 imposed June 7, 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 October 6, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed June 7, 2024. Status: Closed, July 15, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 6, 2023, the nearest before the penalty date.

    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

   Protection From Abuse and Neglect, Cited in Ten Inspections

   Inspectors cited F600 in June 2024, July 2024, August 2024, August 2024, September 2024, October 2024, December 2024, March 2025, August 2025 and September 2025. 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.

   23232323242424242424242424242424242525252525252525262626262626F600 across all 31 inspections, oldest to newest
2. 2

   Care Plans, Cited in Ten Inspections

   Inspectors cited F656 in October 2023, October 2023, April 2024, June 2024, October 2024, December 2024, January 2026, March 2026, April 2026 and April 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.

   23232323242424242424242424242424242525252525252525262626262626F656 across all 31 inspections, oldest to newest
3. 3

   Medical Records, Cited in Ten Inspections

   Inspectors cited F842 in January 2024, February 2024, June 2024, October 2024, October 2024, March 2025, June 2025, January 2026, March 2026 and April 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.

   23232323242424242424242424242424242525252525252525262626262626F842 across all 31 inspections, oldest to newest
4. 4

   Accident Hazards and Supervision, Cited in Seven Inspections

   Inspectors cited F689 in October 2023, November 2023, October 2024, March 2025, January 2026, April 2026 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.

   23232323242424242424242424242424242525252525252525262626262626F689 across all 31 inspections, oldest to newest
5. 5

   Pharmacy Services, Cited in Seven Inspections

   Inspectors cited F755 in October 2023, January 2024, October 2024, January 2025, January 2025, January 2026 and April 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. 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.

   23232323242424242424242424242424242525252525252525262626262626F755 across all 31 inspections, oldest to newest
6. 6

   Infection Control, Cited in Seven Inspections

   Inspectors cited F880 in October 2023, January 2024, August 2024, October 2024, April 2025, January 2026 and June 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.

   23232323242424242424242424242424242525252525252525262626262626F880 across all 31 inspections, oldest to newest
7. 7

   Telling Families About Changes, Cited in Six Inspections

   Inspectors cited F580 in January 2024, June 2024, June 2025, July 2025, January 2026 and April 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232323242424242424242424242424242525252525252525262626262626F580 across all 31 inspections, oldest to newest
8. 8

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in December 2023, April 2024, June 2024, December 2024, January 2026 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232323242424242424242424242424242525252525252525262626262626F684 across all 31 inspections, oldest to newest
9. 9

   Pressure Injury Care, Cited in Five Inspections

   Inspectors cited F686 in October 2023, October 2024, January 2026, April 2026 and June 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.

   23232323242424242424242424242424242525252525252525262626262626F686 across all 31 inspections, oldest to newest
10. 10

    Dignity and Resident Rights, Cited in Four Inspections

    Inspectors cited F550 in October 2023, January 2024, October 2024 and January 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.

    23232323242424242424242424242424242525252525252525262626262626F550 across all 31 inspections, oldest to newest
11. 11

    Needs and Preferences, Cited in Four Inspections

    Inspectors cited F558 in October 2023, June 2024, October 2024 and January 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.

    23232323242424242424242424242424242525252525252525262626262626F558 across all 31 inspections, oldest to newest
12. 12

    Investigating Alleged Violations, Cited in Four Inspections

    Inspectors cited F610 in June 2024, August 2024, March 2025 and March 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. 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.

    23232323242424242424242424242424242525252525252525262626262626F610 across all 31 inspections, oldest to newest
13. 13

    Significant Medication Errors, Cited in Four Inspections

    Inspectors cited F760 in October 2024, December 2024, January 2025 and January 2026. 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.

    23232323242424242424242424242424242525252525252525262626262626F760 across all 31 inspections, oldest to newest
14. 14

    A Clean, Homelike Setting, Cited in Three Inspections

    Inspectors cited F584 in October 2023, October 2024 and January 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

    23232323242424242424242424242424242525252525252525262626262626F584 across all 31 inspections, oldest to newest
15. 15

    Reporting Suspected Abuse, Cited in Three Inspections

    Inspectors cited F609 in October 2023, October 2024 and August 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. 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.

    23232323242424242424242424242424242525252525252525262626262626F609 across all 31 inspections, oldest to newest
16. 16

    The First 48 Hours, Cited in Three Inspections

    Inspectors cited F655 in October 2023, October 2024 and January 2026. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

    23232323242424242424242424242424242525252525252525262626262626F655 across all 31 inspections, oldest to newest
17. 17

    Professional Standards, Cited in Three Inspections

    Inspectors cited F658 in October 2023, October 2024 and January 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

    23232323242424242424242424242424242525252525252525262626262626F658 across all 31 inspections, oldest to newest
18. 18

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in October 2023, January 2026 and June 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. 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.

    23232323242424242424242424242424242525252525252525262626262626F761 across all 31 inspections, oldest to newest
19. 19

    Food Quality and Temperature, Cited in Three Inspections

    Inspectors cited F804 in October 2023, October 2024 and January 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.

    23232323242424242424242424242424242525252525252525262626262626F804 across all 31 inspections, oldest to newest
20. 20

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in October 2023, October 2024 and January 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.

    23232323242424242424242424242424242525252525252525262626262626F812 across all 31 inspections, oldest to newest
21. 21

    Citation F925, Cited in Three Inspections

    Inspectors cited F925 in October 2023, October 2024 and January 2026. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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.

    23232323242424242424242424242424242525252525252525262626262626F925 across all 31 inspections, oldest to newest
22. 22

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in October 2023 and December 2024. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. 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.

    23232323242424242424242424242424242525252525252525262626262626F554 across all 31 inspections, oldest to newest
23. 23

    Citation F576, Cited in Two Inspections

    Inspectors cited F576 in October 2023 and August 2024. The agency describes it this way: Ensure residents have reasonable access to and privacy in their use of communication methods. 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.

    23232323242424242424242424242424242525252525252525262626262626F576 across all 31 inspections, oldest to newest
24. 24

    Treatment Choices and Advance Directives, Cited in Two Inspections

    Inspectors cited F578 in October 2023 and January 2026. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. 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.

    23232323242424242424242424242424242525252525252525262626262626F578 across all 31 inspections, oldest to newest
25. 25

    Citation F583, Cited in Two Inspections

    Inspectors cited F583 in March 2025 and January 2026. The agency describes it this way: Keep residents' personal and medical records private and 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.

    23232323242424242424242424242424242525252525252525262626262626F583 across all 31 inspections, oldest to newest
26. 26

    Citation F604, Cited in Two Inspections

    Inspectors cited F604 in October 2024 and January 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.

    23232323242424242424242424242424242525252525252525262626262626F604 across all 31 inspections, oldest to newest
27. 27

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in October 2023 and October 2024. This citation covers whether each resident’s assessment correctly records their condition. 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.

    23232323242424242424242424242424242525252525252525262626262626F641 across all 31 inspections, oldest to newest
28. 28

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in October 2023 and October 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.

    23232323242424242424242424242424242525252525252525262626262626F677 across all 31 inspections, oldest to newest
29. 29

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in October 2023 and June 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

    23232323242424242424242424242424242525252525252525262626262626F692 across all 31 inspections, oldest to newest
30. 30

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in January 2024 and January 2026. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. 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.

    23232323242424242424242424242424242525252525252525262626262626F697 across all 31 inspections, oldest to newest
31. 31

    Dialysis Care, Cited in Two Inspections

    Inspectors cited F698 in October 2024 and January 2026. This citation covers care for residents who need dialysis. 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.

    23232323242424242424242424242424242525252525252525262626262626F698 across all 31 inspections, oldest to newest
32. 32

    Citation F712, Cited in Two Inspections

    Inspectors cited F712 in June 2024 and March 2025. The agency describes it this way: Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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.

    23232323242424242424242424242424242525252525252525262626262626F712 across all 31 inspections, oldest to newest
33. 33

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in October 2023 and April 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. 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.

    23232323242424242424242424242424242525252525252525262626262626F757 across all 31 inspections, oldest to newest
34. 34

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in October 2023 and October 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. 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.

    23232323242424242424242424242424242525252525252525262626262626F758 across all 31 inspections, oldest to newest
35. 35

    Citation F803, Cited in Two Inspections

    Inspectors cited F803 in October 2024 and January 2026. 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.

    23232323242424242424242424242424242525252525252525262626262626F803 across all 31 inspections, oldest to newest
36. 36

    Citation F805, Cited in Two Inspections

    Inspectors cited F805 in October 2024 and January 2026. The agency describes it this way: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242424242525252525252525262626262626F805 across all 31 inspections, oldest to newest
37. 37

    Citation F849, Cited in Two Inspections

    Inspectors cited F849 in October 2023 and January 2026. The agency describes it this way: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. 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.

    23232323242424242424242424242424242525252525252525262626262626F849 across all 31 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

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

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

2. 02

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

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

3. 03

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

   Medical Records: cited in ten 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 seven inspections, most seriously at level D.

6. 06

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

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

7. 07

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

   Telling Families About Changes: cited in six inspections, most seriously at level D.

8. 08

   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 six inspections, most seriously at level G.

9. 09

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

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

10. 10

    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.

11. 11

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

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

12. 12

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in four inspections, most seriously at level E.

13. 13

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

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

14. 14

    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 E.

15. 15

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in three inspections, most seriously at level D.

16. 16

    What happens in the first 48 hours after admission, and who writes the first care plan?

    The First 48 Hours: cited in three inspections, most seriously at level E.

17. 17

    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.

18. 18

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

    Medication Labeling and Storage: cited in three inspections, most seriously at level D.

19. 19

    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.

20. 20

    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.

21. 21

    What changed after F925 was cited, and how do you check it now?

    Citation F925: cited in three inspections, most seriously at level E.

22. 22

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

23. 23

    What changed after F576 was cited, and how do you check it now?

    Citation F576: cited in two inspections, most seriously at level E.

24. 24

    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 D.

25. 25

    What changed after F583 was cited, and how do you check it now?

    Citation F583: cited in two inspections, most seriously at level E.

26. 26

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

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

27. 27

    Who completes resident assessments, and how are they checked for accuracy?

    Accurate Assessments: cited in two inspections, most seriously at level D.

28. 28

    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.

29. 29

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in two inspections, most seriously at level D.

30. 30

    What changed after F697 was cited, and how do you check it now?

    Citation F697: cited in two inspections, most seriously at level D.

31. 31

    How is dialysis care coordinated, and who monitors residents before and after treatment?

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

32. 32

    What changed after F712 was cited, and how do you check it now?

    Citation F712: cited in two inspections, most seriously at level E.

33. 33

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

34. 34

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

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

35. 35

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

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

36. 36

    What changed after F805 was cited, and how do you check it now?

    Citation F805: cited in two inspections, most seriously at level K.

37. 37

    What changed after F849 was cited, and how do you check it now?

    Citation F849: cited in two inspections, most seriously at level E.

38. 38

    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.

39. 39

    What led to the 2026 fine, and has it been paid?

    A $22,895 civil money penalty was imposed July 21, 2026. CMS publishes the fine, not whether it has been paid. The record holds 11 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 6, 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 Oct 25, 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 14, 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 Dec 4, 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 25, 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 Feb 23, 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 10, 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 7, 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 18, 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 Aug 5, 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 Aug 21, 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 10, 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 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 Oct 24, 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 31, 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 18, 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 24, 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 16, 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 28, 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 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 Apr 28, 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 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 Jul 9, 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 28, 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 Jan 16, 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 3, 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 Apr 14, 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 Apr 29, 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 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 Jul 21, 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 · 555583

  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.