The Vardell Report.Park Avenue Healthcare & Wellness Center

Across 25 inspections from October 2023 to August 2026, state surveyors documented 104 findings at Park Avenue Healthcare & Wellness Center; 104 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

25

2023–2026, standard, complaint and infection control

Findings

104

Deficiencies cited by state inspectors

Corrected

104

Of 104 findings, with a recorded correction date

Penalties

3

3 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 72026

   Standard health inspection

   26 findings

   • 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 28, 2026
   • 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 Sep 2, 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 31, 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 Sep 2, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Aug 31, 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 DNo actual harm, potential for moreCorrected Aug 31, 2026
   • 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 31, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Aug 31, 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 Aug 31, 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 Sep 2, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 1, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 4, 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 Aug 31, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Aug 31, 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 Aug 31, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 31, 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 Aug 31, 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 31, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 31, 2026
   • F917Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Level DNo actual harm, potential for moreCorrected Aug 31, 2026

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

2. Jul 72026

   Complaint investigation

   1 finding

   • 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 Jul 24, 2026

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

3. Feb 52026

   Complaint investigation

   4 findings

   • F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Feb 24, 2026
   • F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Level DNo actual harm, potential for moreCorrected Feb 24, 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 Feb 24, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 24, 2026

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

4. Dec 112025

   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 ENo actual harm, potential for moreCorrected Dec 29, 2025

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

5. Dec 92025

   Complaint investigation

   3 findings

   • 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 31, 2025
   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level DNo actual harm, potential for moreCorrected Dec 29, 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 Dec 29, 2025

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

6. Jul 252025

   Standard health inspection

   16 findings

   • 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 14, 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 Aug 14, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 14, 2025
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Aug 14, 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 Aug 14, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Aug 14, 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 Aug 13, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 13, 2025
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Aug 14, 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 Aug 14, 2025
   • 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 Aug 14, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 14, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Aug 14, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Aug 14, 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 Aug 14, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Aug 13, 2025

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

7. Jun 32025

   Complaint investigation

   5 findings

   • 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 Jun 23, 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 Jun 23, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 23, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 23, 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 23, 2025

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

8. Apr 162025

   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 GActual harmCorrected May 5, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected May 5, 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 5, 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 May 5, 2025

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

9. Mar 282025

   Complaint investigation

   3 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 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 Apr 21, 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 21, 2025

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

10. Mar 102025

    Complaint investigation

    3 findings

    • 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 Mar 19, 2025
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Mar 27, 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 DNo actual harm, potential for moreCorrected Mar 21, 2025

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

11. Jan 292025

    Complaint investigation

    2 findings

    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Feb 13, 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 Feb 13, 2025

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

12. Jan 162025

    Complaint investigation

    3 findings

    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level KImmediate jeopardyCorrected Feb 3, 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 Feb 3, 2025
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 4, 2025

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

13. Nov 262024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 6, 2024

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

14. Sep 182024

    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 Oct 4, 2024

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

15. Aug 52024

    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 Aug 12, 2024

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

16. Jul 112024

    Standard health inspection

    15 findings

    The same visit included a complaint investigation.

    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Jul 11, 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 Aug 2, 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 ENo actual harm, potential for moreCorrected Aug 2, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Aug 13, 2024
    • 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 2, 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 Aug 2, 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 Jul 25, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 1, 2024
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Aug 8, 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 Jul 31, 2024
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 25, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 2, 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 Jul 25, 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 DNo actual harm, potential for moreCorrected Aug 8, 2024

    Enforcement Action

    Civil money penalty, $23,403 imposed January 16, 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 July 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $32,646 imposed March 28, 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 July 11, 2024, the nearest before the penalty date.

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

17. Jun 182024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 2, 2024

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

18. Jun 62024

    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 Jun 24, 2024

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

19. May 132024

    Complaint investigation

    4 findings

    • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level ENo actual harm, potential for moreCorrected May 15, 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 May 15, 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 15, 2024
    • 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 15, 2024

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

20. Apr 182024

    Complaint investigation

    3 findings

    • 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 10, 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 May 10, 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 10, 2024

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

21. Feb 152024

    Complaint investigation

    1 finding

    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Mar 5, 2024

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

22. Feb 72024

    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 Feb 28, 2024

    Enforcement Action

    Civil money penalty, $28,009 imposed February 7, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of February 7, 2024, the nearest before the penalty date.

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

23. Dec 212023

    Infection control inspection

    1 finding

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 17, 2024

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

24. Nov 82023

    Complaint investigation

    1 finding

    • 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 30, 2023

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

25. Oct 312023

    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 Nov 13, 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 Nov 12, 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

   Care Plans, Cited in Eight Inspections

   Inspectors cited F656 in April 2024, July 2024, September 2024, March 2025, April 2025, June 2025, July 2025 and August 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.

   23232324242424242424242424252525252525252525262626F656 across all 25 inspections, oldest to newest
2. 2

   Medical Records, Cited in Seven Inspections

   Inspectors cited F842 in January 2025, January 2025, March 2025, June 2025, July 2025, December 2025 and August 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.

   23232324242424242424242424252525252525252525262626F842 across all 25 inspections, oldest to newest
3. 3

   Infection Control, Cited in Seven Inspections

   Inspectors cited F880 in December 2023, June 2024, July 2024, November 2024, January 2025, July 2025 and August 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.

   23232324242424242424242424252525252525252525262626F880 across all 25 inspections, oldest to newest
4. 4

   Dignity and Resident Rights, Cited in Six Inspections

   Inspectors cited F550 in April 2024, May 2024, July 2024, March 2025, July 2025 and August 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.

   23232324242424242424242424252525252525252525262626F550 across all 25 inspections, oldest to newest
5. 5

   Protection From Abuse and Neglect, Cited in Six Inspections

   Inspectors cited F600 in October 2023, February 2024, April 2024, June 2024, April 2025 and August 2026. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

   23232324242424242424242424252525252525252525262626F600 across all 25 inspections, oldest to newest
6. 6

   Quality of Care, Cited in Five Inspections

   Inspectors cited F684 in July 2024, June 2025, July 2025, February 2026 and August 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.

   23232324242424242424242424252525252525252525262626F684 across all 25 inspections, oldest to newest
7. 7

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in August 2024, March 2025, April 2025, July 2025 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. 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.

   23232324242424242424242424252525252525252525262626F689 across all 25 inspections, oldest to newest
8. 8

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in July 2024, February 2026 and August 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232324242424242424242424252525252525252525262626F657 across all 25 inspections, oldest to newest
9. 9

   Respiratory Care, Cited in Three Inspections

   Inspectors cited F695 in July 2024, July 2025 and August 2026. This citation covers oxygen, breathing treatments and other respiratory care. 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.

   23232324242424242424242424252525252525252525262626F695 across all 25 inspections, oldest to newest
10. 10

    Citation F806, Cited in Three Inspections

    Inspectors cited F806 in May 2024, July 2024 and August 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.

    23232324242424242424242424252525252525252525262626F806 across all 25 inspections, oldest to newest
11. 11

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in July 2024, July 2025 and August 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.

    23232324242424242424242424252525252525252525262626F812 across all 25 inspections, oldest to newest
12. 12

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in July 2024 and April 2025. 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.

    23232324242424242424242424252525252525252525262626F558 across all 25 inspections, oldest to newest
13. 13

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in December 2025 and August 2026. 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.

    23232324242424242424242424252525252525252525262626F584 across all 25 inspections, oldest to newest
14. 14

    Reporting Suspected Abuse, Cited in Two Inspections

    Inspectors cited F609 in October 2023 and November 2023. 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.

    23232324242424242424242424252525252525252525262626F609 across all 25 inspections, oldest to newest
15. 15

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in July 2024 and August 2026. 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.

    23232324242424242424242424252525252525252525262626F641 across all 25 inspections, oldest to newest
16. 16

    Pre-Admission Screening, Cited in Two Inspections

    Inspectors cited F645 in July 2025 and August 2026. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). 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.

    23232324242424242424242424252525252525252525262626F645 across all 25 inspections, oldest to newest
17. 17

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in June 2025 and August 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

    23232324242424242424242424252525252525252525262626F686 across all 25 inspections, oldest to newest
18. 18

    Continence and Catheter Care, Cited in Two Inspections

    Inspectors cited F690 in July 2025 and August 2026. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

    23232324242424242424242424252525252525252525262626F690 across all 25 inspections, oldest to newest
19. 19

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in July 2025 and August 2026. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242424242424252525252525252525262626F693 across all 25 inspections, oldest to newest
20. 20

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in July 2024 and August 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.

    23232324242424242424242424252525252525252525262626F755 across all 25 inspections, oldest to newest
21. 21

    Citation F808, Cited in Two Inspections

    Inspectors cited F808 in May 2024 and December 2025. The agency describes it this way: Ensure 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. 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.

    23232324242424242424242424252525252525252525262626F808 across all 25 inspections, oldest to newest
22. 22

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in July 2024 and January 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

    23232324242424242424242424252525252525252525262626F883 across all 25 inspections, oldest to newest
23. 23

    Citation F919, Cited in Two Inspections

    Inspectors cited F919 in July 2025 and August 2026. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. 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.

    23232324242424242424242424252525252525252525262626F919 across all 25 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 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.

2. 02

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

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

4. 04

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

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

5. 05

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

   Protection From Abuse and Neglect: cited in six inspections, most seriously at level G.

6. 06

   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 five inspections, most seriously at level D.

7. 07

   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 five inspections, most seriously at level E.

8. 08

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

   Care Plan Timing and Review: cited in three inspections, most seriously at level E.

9. 09

   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 D.

10. 10

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

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

11. 11

    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.

12. 12

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

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

13. 13

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

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

14. 14

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

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

15. 15

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

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

16. 16

    Was the required pre-admission screening done for every resident, and how is it tracked?

    Pre-Admission Screening: cited in two inspections, most seriously at level D.

17. 17

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

    Pressure Injury Care: cited in two inspections, most seriously at level D.

18. 18

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

    Continence and Catheter Care: cited in two inspections, most seriously at level E.

19. 19

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

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

20. 20

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

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

21. 21

    What changed after F808 was cited, and how do you check it now?

    Citation F808: cited in two inspections, most seriously at level D.

22. 22

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level K.

23. 23

    What changed after F919 was cited, and how do you check it now?

    Citation F919: cited in two inspections, most seriously at level E.

24. 24

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

    Insufficient nursing staff was cited in August 2026.

25. 25

    What led to the 2025 fine, and has it been paid?

    A $32,646 civil money penalty was imposed March 28, 2025. CMS publishes the fine, not whether it has been paid. The record holds three 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 31, 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 8, 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 21, 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 Feb 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 Feb 15, 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 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 May 13, 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 6, 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 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 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 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 Sep 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 Nov 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 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 29, 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 10, 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 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 Apr 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 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 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 Dec 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 Dec 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 Feb 5, 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 Aug 7, 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 · 555852

  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.