The Vardell Report.Santa Anita Convalescent Hospital

Across 59 inspections from October 2023 to August 2026, state surveyors documented 174 findings at Santa Anita Convalescent Hospital; 174 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

59

2023–2026, complaint and standard

Findings

174

Deficiencies cited by state inspectors

Corrected

174

Of 174 findings, with a recorded correction date

Penalties

5

4 fines; payment not published, 1 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. Aug 212026

   Complaint investigation

   1 finding

   • 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 3, 2026

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

2. Jul 302026

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 24, 2026

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

3. Jun 152026

   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 Jul 6, 2026

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

4. Jun 122026

   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 Jul 1, 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 1, 2026

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

5. Jun 52026

   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 Jul 1, 2026

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

6. May 292026

   Standard health inspection

   21 findings

   The same visit included a complaint investigation.

   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level ENo actual harm, potential for moreCorrected Jun 22, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Jun 22, 2026
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jun 22, 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 Jun 22, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 22, 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 ENo actual harm, potential for moreCorrected Jun 22, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 22, 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 Jun 22, 2026
   • 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 Jun 22, 2026
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Jun 22, 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 Jun 22, 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 Jun 22, 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 DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 22, 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 DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level DNo actual harm, potential for moreCorrected Jun 22, 2026

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

7. Apr 302026

   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 May 22, 2026

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

8. Apr 72026

   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 May 1, 2026

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

9. Mar 52026

   Complaint investigation

   2 findings

   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • F555Honor the resident's right to choose his or her attending physician.Level DNo actual harm, potential for moreCorrected Apr 3, 2026

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

10. Jan 52026

    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 Jan 29, 2026

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

11. Dec 42025

    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 Dec 24, 2025

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

12. Nov 242025

    Complaint investigation

    1 finding

    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 25, 2025

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

13. Nov 52025

    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 Dec 7, 2025

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

14. Aug 282025

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 19, 2025

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

15. Aug 272025

    Complaint investigation

    2 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 Aug 28, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 16, 2025

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

16. Aug 152025

    Complaint investigation

    2 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 24, 2025
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Aug 24, 2025

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

17. Aug 132025

    Complaint investigation

    2 findings

    • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Aug 24, 2025
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Aug 24, 2025

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

18. Jul 312025

    Complaint investigation

    1 finding

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 22, 2025

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

19. Jul 172025

    Complaint investigation

    2 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 8, 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 8, 2025

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

20. Jun 262025

    Complaint investigation

    5 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Jun 25, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jul 15, 2025
    • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level ENo actual harm, potential for moreCorrected Jul 15, 2025
    • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2025

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

21. Jun 182025

    Complaint investigation

    1 finding

    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 11, 2025

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

22. Jun 172025

    Complaint investigation

    4 findings

    • 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 11, 2025
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
    • 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 Jul 11, 2025

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

23. May 82025

    Standard health inspection

    25 findings

    The same visit included a complaint investigation.

    • 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 Jun 1, 2025
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 1, 2025
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 1, 2025
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jun 1, 2025
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jun 1, 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 Jun 1, 2025
    • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level ENo actual harm, potential for moreCorrected Jun 1, 2025
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Jun 1, 2025
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 1, 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 Jun 1, 2025
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • 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 Jun 1, 2025
    • 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 1, 2025
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • 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 Jun 1, 2025
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 1, 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 Jun 1, 2025
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • 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 Jun 1, 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 1, 2025
    • F848Provide a neutral and fair arbitration process and agree to arbitrator and venue.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jun 1, 2025
    • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Jun 1, 2025

    Enforcement Action

    Civil money penalty, $50,935 imposed June 17, 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 May 8, 2025, the nearest before the penalty date.

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

24. Apr 162025

    Complaint investigation

    2 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 DNo actual harm, potential for moreCorrected May 6, 2025
    • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected May 6, 2025

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

25. Apr 32025

    Complaint investigation

    2 findings

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 24, 2025
    • F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Apr 24, 2025

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

26. Feb 272025

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 17, 2025

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

27. Feb 252025

    Complaint investigation

    2 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 25, 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 Feb 25, 2025

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

28. Feb 212025

    Complaint investigation

    1 finding

    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Feb 25, 2025

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

29. Jan 292025

    Complaint investigation

    3 findings

    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Feb 24, 2025
    • F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Level DNo actual harm, potential for moreCorrected Feb 24, 2025
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 24, 2025

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

30. Jan 82025

    Complaint investigation

    3 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jan 22, 2025
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jan 22, 2025
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jan 22, 2025

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

31. Oct 182024

    Complaint investigation

    2 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Nov 10, 2024
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Nov 10, 2024

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

32. Sep 262024

    Complaint investigation

    3 findings

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 18, 2024

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

33. Sep 252024

    Complaint investigation

    3 findings

    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
    • 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 18, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 18, 2024

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

34. Sep 192024

    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 ENo actual harm, potential for moreCorrected Oct 10, 2024
    • 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 10, 2024

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

35. Sep 42024

    Complaint investigation

    2 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 17, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Sep 17, 2024

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

36. Aug 262024

    Complaint investigation

    1 finding

    • 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 10, 2024

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

37. Aug 162024

    Complaint investigation

    6 findings

    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Sep 6, 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 Sep 6, 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 Sep 6, 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 Sep 6, 2024
    • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 6, 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 Sep 6, 2024

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

38. Aug 142024

    Complaint investigation

    1 finding

    • 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 26, 2024

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

39. Aug 92024

    Complaint investigation

    2 findings

    • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Aug 26, 2024
    • 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 26, 2024

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

40. Jul 272024

    Complaint investigation

    3 findings

    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Aug 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 23, 2024
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Aug 23, 2024

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

41. May 252024

    Standard health inspection

    30 findings

    The same visit included a complaint investigation.

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 23, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Jun 23, 2024
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Jun 23, 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 Jun 23, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jun 23, 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 Jun 23, 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 Jun 23, 2024
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jun 23, 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 Jun 23, 2024
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Jun 23, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 23, 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 Jun 23, 2024
    • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • 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 Jun 23, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 23, 2024
    • 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 Jun 23, 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 DNo actual harm, potential for moreCorrected Jun 23, 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 Jun 23, 2024
    • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Jun 23, 2024

    Enforcement Action

    Civil money penalty, $75,208 imposed May 25, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 25, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $21,548 imposed January 8, 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 May 25, 2024, the nearest before the penalty date.

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

42. May 102024

    Complaint investigation

    1 finding

    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.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)

43. Apr 242024

    Complaint investigation

    1 finding

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected May 9, 2024

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

44. Apr 232024

    Complaint investigation

    2 findings

    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected May 15, 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 May 15, 2024

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

45. Apr 192024

    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 May 9, 2024

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

46. Apr 142024

    Complaint investigation

    2 findings

    • F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level KImmediate jeopardyCorrected May 9, 2024
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected May 9, 2024

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

47. Apr 32024

    Complaint investigation

    1 finding

    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 30, 2024

    Enforcement Action

    Civil money penalty, $86,496 imposed April 3, 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 April 3, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed April 3, 2024. Status: Closed, May 15, 2024. CMS does not tie a penalty to a survey; listed with the complaint investigation of April 3, 2024, the nearest before the penalty date.

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

48. Mar 132024

    Complaint investigation

    1 finding

    • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Mar 29, 2024

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

49. Mar 62024

    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 Mar 26, 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 Mar 26, 2024

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

50. Feb 132024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 4, 2024

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

51. Feb 52024

    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 Mar 4, 2024

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

52. Jan 272024

    Complaint investigation

    1 finding

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Feb 24, 2024

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

53. Jan 92024

    Complaint investigation

    1 finding

    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Feb 2, 2024

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

54. Jan 82024

    Complaint investigation

    2 findings

    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jan 30, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jan 30, 2024

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

55. Dec 272023

    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 Jan 18, 2024

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

56. Dec 62023

    Complaint investigation

    1 finding

    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jan 5, 2024

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

57. Nov 152023

    Complaint investigation

    4 findings

    • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected Dec 11, 2023
    • 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 Dec 11, 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 Dec 11, 2023
    • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Dec 11, 2023

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

58. Oct 132023

    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 31, 2023

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

59. Oct 62023

    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 30, 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

   Accident Hazards and Supervision, Cited in 13 Inspections

   Inspectors cited F689 in November 2023, April 2024, May 2024, August 2024, September 2024, January 2025, May 2025, June 2025, June 2025, August 2025, November 2025, January 2026 and May 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F689 across all 59 inspections, oldest to newest
2. 2

   Care Plans, Cited in Ten Inspections

   Inspectors cited F656 in October 2023, December 2023, February 2024, March 2024, May 2024, August 2024, June 2025, December 2025, May 2026 and June 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F656 across all 59 inspections, oldest to newest
3. 3

   Medical Records, Cited in Nine Inspections

   Inspectors cited F842 in April 2024, May 2024, August 2024, May 2025, July 2025, April 2026, May 2026, June 2026 and June 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F842 across all 59 inspections, oldest to newest
4. 4

   Dignity and Resident Rights, Cited in Eight Inspections

   Inspectors cited F550 in May 2024, August 2024, February 2025, May 2025, June 2025, July 2025, August 2025 and May 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F550 across all 59 inspections, oldest to newest
5. 5

   Protection From Abuse and Neglect, Cited in Seven Inspections

   Inspectors cited F600 in October 2023, March 2024, April 2024, July 2024, September 2024, May 2025 and June 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F600 across all 59 inspections, oldest to newest
6. 6

   Quality of Care, Cited in Six Inspections

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

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F684 across all 59 inspections, oldest to newest
7. 7

   Pharmacy Services, Cited in Six Inspections

   Inspectors cited F755 in November 2023, May 2024, August 2024, May 2025, June 2025 and May 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F755 across all 59 inspections, oldest to newest
8. 8

   Infection Control, Cited in Six Inspections

   Inspectors cited F880 in May 2024, September 2024, February 2025, May 2025, August 2025 and May 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F880 across all 59 inspections, oldest to newest
9. 9

   Needs and Preferences, Cited in Five Inspections

   Inspectors cited F558 in May 2024, September 2024, May 2025, July 2025 and May 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.

   2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F558 across all 59 inspections, oldest to newest
10. 10

    Care Plan Timing and Review, Cited in Five Inspections

    Inspectors cited F657 in May 2024, August 2024, September 2024, May 2025 and May 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F657 across all 59 inspections, oldest to newest
11. 11

    Pressure Injury Care, Cited in Five Inspections

    Inspectors cited F686 in January 2024, May 2024, January 2025, January 2025 and May 2025. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F686 across all 59 inspections, oldest to newest
12. 12

    Medication Labeling and Storage, Cited in Five Inspections

    Inspectors cited F761 in May 2024, July 2024, January 2025, May 2025 and May 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F761 across all 59 inspections, oldest to newest
13. 13

    Citation F607, Cited in Four Inspections

    Inspectors cited F607 in January 2024, May 2024, July 2024 and October 2024. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F607 across all 59 inspections, oldest to newest
14. 14

    Accurate Assessments, Cited in Four Inspections

    Inspectors cited F641 in May 2025, June 2025, November 2025 and May 2026. This citation covers whether each resident’s assessment correctly records their condition. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F641 across all 59 inspections, oldest to newest
15. 15

    Citation F676, Cited in Four Inspections

    Inspectors cited F676 in November 2023, May 2024, August 2024 and September 2024. The agency describes it this way: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F676 across all 59 inspections, oldest to newest
16. 16

    Help With Daily Living, Cited in Four Inspections

    Inspectors cited F677 in April 2024, May 2024, April 2025 and May 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F677 across all 59 inspections, oldest to newest
17. 17

    Respiratory Care, Cited in Four Inspections

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

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F695 across all 59 inspections, oldest to newest
18. 18

    Citation F921, Cited in Four Inspections

    Inspectors cited F921 in December 2023, January 2025, May 2025 and August 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F921 across all 59 inspections, oldest to newest
19. 19

    Citation F552, Cited in Three Inspections

    Inspectors cited F552 in May 2024, March 2026 and May 2026. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F552 across all 59 inspections, oldest to newest
20. 20

    Reporting Suspected Abuse, Cited in Three Inspections

    Inspectors cited F609 in January 2024, April 2026 and June 2026. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F609 across all 59 inspections, oldest to newest
21. 21

    Continence and Catheter Care, Cited in Three Inspections

    Inspectors cited F690 in May 2024, April 2025 and May 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F690 across all 59 inspections, oldest to newest
22. 22

    Dialysis Care, Cited in Three Inspections

    Inspectors cited F698 in May 2024, May 2025 and May 2026. This citation covers care for residents who need dialysis. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F698 across all 59 inspections, oldest to newest
23. 23

    Garbage and Refuse, Cited in Three Inspections

    Inspectors cited F814 in May 2024, May 2025 and August 2025. This citation covers whether garbage and refuse are disposed of properly. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F814 across all 59 inspections, oldest to newest
24. 24

    A Clean, Homelike Setting, Cited in Two Inspections

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

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F584 across all 59 inspections, oldest to newest
25. 25

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in September 2024 and February 2025. This citation covers whether the home’s services meet professional standards of quality. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F658 across all 59 inspections, oldest to newest
26. 26

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in September 2024 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F692 across all 59 inspections, oldest to newest
27. 27

    Medication Error Rate, Cited in Two Inspections

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

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F759 across all 59 inspections, oldest to newest
28. 28

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in January 2024 and August 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F804 across all 59 inspections, oldest to newest
29. 29

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in May 2024 and May 2025. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F812 across all 59 inspections, oldest to newest
30. 30

    Citation F813, Cited in Two Inspections

    Inspectors cited F813 in May 2025 and May 2026. The agency describes it this way: Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F813 across all 59 inspections, oldest to newest
31. 31

    Citation F912, Cited in Two Inspections

    Inspectors cited F912 in May 2024 and May 2025. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F912 across all 59 inspections, oldest to newest
32. 32

    Citation F919, Cited in Two Inspections

    Inspectors cited F919 in November 2023 and August 2024. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232323242424242424242424242424242424242424242424242424252525252525252525252525252525252525252526262626262626262626F919 across all 59 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 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 13 inspections, most seriously at level G.

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 nine 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 eight 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 seven inspections, most seriously at level J.

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 six inspections, most seriously at level E.

7. 07

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

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

8. 08

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

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

9. 09

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

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

10. 10

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

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

11. 11

    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.

12. 12

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

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

13. 13

    What changed after F607 was cited, and how do you check it now?

    Citation F607: cited in four inspections, most seriously at level D.

14. 14

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

    Accurate Assessments: cited in four inspections, most seriously at level E.

15. 15

    What changed after F676 was cited, and how do you check it now?

    Citation F676: cited in four inspections, most seriously at level E.

16. 16

    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 four inspections, most seriously at level E.

17. 17

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

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

18. 18

    What changed after F921 was cited, and how do you check it now?

    Citation F921: cited in four inspections, most seriously at level D.

19. 19

    What changed after F552 was cited, and how do you check it now?

    Citation F552: cited in three inspections, most seriously at level E.

20. 20

    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.

21. 21

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

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

22. 22

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

    Dialysis Care: cited in three inspections, most seriously at level D.

23. 23

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in three inspections, most seriously at level E.

24. 24

    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.

25. 25

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

    Professional Standards: cited in two inspections, most seriously at level D.

26. 26

    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.

27. 27

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

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

28. 28

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

    Food Quality and Temperature: cited in two inspections, most seriously at level D.

29. 29

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

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

30. 30

    What changed after F813 was cited, and how do you check it now?

    Citation F813: cited in two inspections, most seriously at level E.

31. 31

    What changed after F912 was cited, and how do you check it now?

    Citation F912: cited in two inspections, most seriously at level B.

32. 32

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

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

33. 33

    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.

34. 34

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

    A $50,935 civil money penalty was imposed June 17, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.