The Vardell Report.Sunland Post Acute

Across 25 inspections from October 2023 to May 2026, state surveyors documented 110 findings at Sunland Post Acute; 110 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

25

2023–2026, complaint and standard

Findings

110

Deficiencies cited by state inspectors

Corrected

110

Of 110 findings, with a recorded correction date

Penalties

5

3 fines; payment not published, 2 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. May 62026

   Complaint investigation

   2 findings

   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected May 27, 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 May 27, 2026

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

2. Apr 222026

   Complaint investigation

   2 findings

   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected May 13, 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 May 13, 2026

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

3. Apr 12026

   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 Apr 15, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Apr 15, 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 Apr 15, 2026

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

4. Jan 152026

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 4, 2026

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

5. Dec 42025

   Standard health inspection

   19 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level FNo actual harm, potential for moreCorrected Dec 23, 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 FNo actual harm, potential for moreCorrected Dec 23, 2025
   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Dec 23, 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 ENo actual harm, potential for moreCorrected Dec 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 ENo actual harm, potential for moreCorrected Dec 23, 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 Dec 23, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Dec 23, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • 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 Dec 23, 2025
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Dec 23, 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 Dec 23, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • 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 Dec 23, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Dec 23, 2025
   • 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 Dec 23, 2025

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

6. Sep 112025

   Complaint investigation

   7 findings

   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Sep 12, 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 Sep 12, 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 Sep 25, 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 DNo actual harm, potential for moreCorrected Sep 24, 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 Sep 25, 2025
   • 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 Sep 25, 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 Sep 26, 2025

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

7. Aug 52025

   Complaint investigation

   2 findings

   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreCorrected Aug 8, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Aug 21, 2025

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

8. May 52025

   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 29, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Level DNo actual harm, potential for moreCorrected May 29, 2025

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

9. Feb 202025

   Complaint investigation

   1 finding

   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Mar 13, 2025

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

10. Jan 312025

    Complaint investigation

    3 findings

    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Mar 14, 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 Mar 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 Mar 14, 2025

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

11. Dec 272024

    Complaint investigation

    1 finding

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Dec 31, 2024

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

12. Dec 112024

    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 Dec 25, 2024

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

13. Nov 122024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 4, 2024

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

14. Oct 222024

    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 Nov 15, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 15, 2024

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

15. Oct 112024

    Standard health inspection

    19 findings

    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level GActual harmCorrected Nov 7, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Nov 7, 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 Dec 16, 2024
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Nov 7, 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 Nov 7, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
    • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 7, 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 Nov 7, 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 Nov 7, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 7, 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 Nov 7, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 7, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Nov 7, 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 DNo actual harm, potential for moreCorrected Dec 16, 2024
    • 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 Dec 16, 2024

    Enforcement Action

    Civil money penalty, $80,876 imposed October 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed October 11, 2024. Status: Closed, December 26, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $54,560 imposed May 5, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.

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

16. Sep 242024

    Complaint investigation

    4 findings

    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Oct 17, 2024
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Oct 17, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 17, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 17, 2024

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

17. Sep 122024

    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 Oct 4, 2024

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

18. Jul 102024

    Complaint investigation

    4 findings

    • F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected Aug 2, 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 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 Aug 2, 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 Aug 2, 2024

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

19. May 312024

    Complaint investigation

    2 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 10, 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 10, 2024

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

20. Apr 82024

    Complaint investigation

    1 finding

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 17, 2024

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

21. Mar 192024

    Complaint investigation

    2 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 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 May 16, 2024

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

22. Dec 282023

    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 Jan 22, 2024

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

23. Nov 292023

    Complaint investigation

    5 findings

    • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • 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 Dec 23, 2023
    • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • 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 Dec 27, 2023

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

24. Nov 72023

    Complaint investigation

    1 finding

    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 15, 2023

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

25. Oct 202023

    Standard health inspection

    20 findings

    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Nov 16, 2023
    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Nov 16, 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 Nov 16, 2023
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • 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 Nov 16, 2023
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Dec 29, 2023
    • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Nov 16, 2023
    • 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 Nov 16, 2023
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Dec 29, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 16, 2023
    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 16, 2023
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Nov 16, 2023
    • 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 Nov 16, 2023
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Nov 16, 2023
    • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level DNo actual harm, potential for moreCorrected Nov 16, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 16, 2023

    Enforcement Action

    Civil money penalty, $104,845 imposed October 20, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 20, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed October 20, 2023. Status: Closed, January 23, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 20, 2023, the nearest before the penalty date.

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

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

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

1. 1

   Care Plans, Cited in Seven Inspections

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

   23232323242424242424242424242425252525252526262626F656 across all 25 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in October 2023, September 2024, October 2024, October 2024, December 2025 and January 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.

   23232323242424242424242424242425252525252526262626F684 across all 25 inspections, oldest to newest
3. 3

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in October 2023, March 2024, October 2024, January 2025 and December 2025. 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.

   23232323242424242424242424242425252525252526262626F689 across all 25 inspections, oldest to newest
4. 4

   Kitchen and Food Safety, Cited in Five Inspections

   Inspectors cited F812 in October 2023, November 2023, October 2024, September 2025 and December 2025. This citation covers how food is stored, prepared and served. 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.

   23232323242424242424242424242425252525252526262626F812 across all 25 inspections, oldest to newest
5. 5

   Medical Records, Cited in Five Inspections

   Inspectors cited F842 in October 2023, May 2024, July 2024, September 2024 and April 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232323242424242424242424242425252525252526262626F842 across all 25 inspections, oldest to newest
6. 6

   Citation F552, Cited in Four Inspections

   Inspectors cited F552 in October 2023, September 2024, October 2024 and December 2025. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. 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.

   23232323242424242424242424242425252525252526262626F552 across all 25 inspections, oldest to newest
7. 7

   Pharmacy Services, Cited in Four Inspections

   Inspectors cited F755 in October 2023, October 2024, September 2025 and December 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232323242424242424242424242425252525252526262626F755 across all 25 inspections, oldest to newest
8. 8

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in October 2023, May 2024, October 2024 and November 2024. 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.

   23232323242424242424242424242425252525252526262626F880 across all 25 inspections, oldest to newest
9. 9

   Needs and Preferences, Cited in Three Inspections

   Inspectors cited F558 in October 2023, September 2024 and December 2024. 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.

   23232323242424242424242424242425252525252526262626F558 across all 25 inspections, oldest to newest
10. 10

    Telling Families About Changes, Cited in Three Inspections

    Inspectors cited F580 in November 2023, May 2025 and December 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F580 across all 25 inspections, oldest to newest
11. 11

    Protection From Abuse and Neglect, Cited in Three Inspections

    Inspectors cited F600 in December 2023, May 2025 and May 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.

    23232323242424242424242424242425252525252526262626F600 across all 25 inspections, oldest to newest
12. 12

    Reporting Suspected Abuse, Cited in Three Inspections

    Inspectors cited F609 in September 2024, December 2024 and May 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F609 across all 25 inspections, oldest to newest
13. 13

    Care Plan Timing and Review, Cited in Three Inspections

    Inspectors cited F657 in October 2024, January 2025 and December 2025. 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.

    23232323242424242424242424242425252525252526262626F657 across all 25 inspections, oldest to newest
14. 14

    Nutrition and Hydration, Cited in Three Inspections

    Inspectors cited F692 in October 2023, October 2024 and December 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

    23232323242424242424242424242425252525252526262626F692 across all 25 inspections, oldest to newest
15. 15

    Psychotropic Medications, Cited in Three Inspections

    Inspectors cited F758 in October 2023, October 2024 and February 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F758 across all 25 inspections, oldest to newest
16. 16

    Medication Labeling and Storage, Cited in Three Inspections

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

    23232323242424242424242424242425252525252526262626F761 across all 25 inspections, oldest to newest
17. 17

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in October 2023 and April 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.

    23232323242424242424242424242425252525252526262626F550 across all 25 inspections, oldest to newest
18. 18

    Treatment Choices and Advance Directives, Cited in Two Inspections

    Inspectors cited F578 in October 2023 and December 2025. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F578 across all 25 inspections, oldest to newest
19. 19

    Citation F582, Cited in Two Inspections

    Inspectors cited F582 in December 2025 and May 2026. The agency describes it this way: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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.

    23232323242424242424242424242425252525252526262626F582 across all 25 inspections, oldest to newest
20. 20

    Citation F583, Cited in Two Inspections

    Inspectors cited F583 in October 2024 and December 2025. The agency describes it this way: Keep residents' personal and medical records private and confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F583 across all 25 inspections, oldest to newest
21. 21

    A Clean, Homelike Setting, Cited in Two Inspections

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

    23232323242424242424242424242425252525252526262626F584 across all 25 inspections, oldest to newest
22. 22

    Citation F628, Cited in Two Inspections

    Inspectors cited F628 in August 2025 and April 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. 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.

    23232323242424242424242424242425252525252526262626F628 across all 25 inspections, oldest to newest
23. 23

    Help With Daily Living, Cited in Two Inspections

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

    23232323242424242424242424242425252525252526262626F677 across all 25 inspections, oldest to newest
24. 24

    Citation F694, Cited in Two Inspections

    Inspectors cited F694 in October 2023 and October 2024. The agency describes it this way: Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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.

    23232323242424242424242424242425252525252526262626F694 across all 25 inspections, oldest to newest
25. 25

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in October 2024 and December 2025. 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.

    23232323242424242424242424242425252525252526262626F695 across all 25 inspections, oldest to newest
26. 26

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in October 2024 and January 2026. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F697 across all 25 inspections, oldest to newest
27. 27

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in November 2023 and July 2024. The agency describes it this way: Post nurse staffing information every day. 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.

    23232323242424242424242424242425252525252526262626F732 across all 25 inspections, oldest to newest
28. 28

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in October 2023 and October 2024. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232323242424242424242424242425252525252526262626F760 across all 25 inspections, oldest to newest
29. 29

    Citation F806, Cited in Two Inspections

    Inspectors cited F806 in July 2024 and September 2025. 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.

    23232323242424242424242424242425252525252526262626F806 across all 25 inspections, oldest to newest
30. 30

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in October 2023 and December 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

    23232323242424242424242424242425252525252526262626F883 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 seven inspections, most seriously at level E.

2. 02

   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 D.

3. 03

   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 G.

4. 04

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

   Kitchen and Food Safety: cited in five inspections, most seriously at level D.

5. 05

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

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

6. 06

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

   Citation F552: cited in four inspections, most seriously at level D.

7. 07

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

   Pharmacy Services: cited in four inspections, most seriously at level F.

8. 08

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

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

10. 10

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

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

11. 11

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

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

12. 12

    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.

13. 13

    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 D.

14. 14

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

    Nutrition and Hydration: cited in three inspections, most seriously at level G.

15. 15

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

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

16. 16

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

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

17. 17

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

    Dignity and Resident Rights: cited in two inspections, most seriously at level D.

18. 18

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

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

19. 19

    What changed after F582 was cited, and how do you check it now?

    Citation F582: cited in two inspections, most seriously at level D.

20. 20

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

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

21. 21

    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 E.

22. 22

    What changed after F628 was cited, and how do you check it now?

    Citation F628: cited in two inspections, most seriously at level D.

23. 23

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

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

24. 24

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

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

25. 25

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

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

26. 26

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

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

27. 27

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in two inspections, most seriously at level E.

28. 28

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

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

29. 29

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

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

30. 30

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

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

31. 31

    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.

32. 32

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

    A $54,560 civil money penalty was imposed May 5, 2025. CMS publishes the fine, not whether it has been paid. The record holds five 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 20, 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 7, 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 29, 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 28, 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 Mar 19, 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 8, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

  Inspection May 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

  Inspection Jul 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

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

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

  California state survey agency

  Inspection Sep 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

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

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

  California state survey agency

  Inspection Oct 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

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

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

  California state survey agency

  Inspection Dec 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 Dec 27, 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 31, 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 20, 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 May 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

  Inspection Aug 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

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

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

  California state survey agency

  Inspection Jan 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

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

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

  California state survey agency

  Inspection Apr 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  California state survey agency

  Inspection May 6, 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 · 056031

  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.