The Vardell Report.Bishop Drumm Retirement Center

Across 15 inspections from June 2023 to August 2026, state surveyors documented 80 findings at Bishop Drumm Retirement Center; 79 have a recorded correction and 1 awaits one; CMS lists 7 enforcement actions in the window.

Inspections

15

2023–2026, complaint and standard

Findings

80

Deficiencies cited by state inspectors

Corrected

79

Of 80 findings, with a recorded correction date

Penalties

7

4 fines; payment not published, 3 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 132026

   Complaint investigation

   1 finding

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction

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

2. Jun 112026

   Complaint investigation

   6 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 Jul 1, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 1, 2026
   • 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 Jul 1, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jul 1, 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 Jul 1, 2026
   • F880Provide and implement an infection prevention and control program.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)

3. Feb 182026

   Complaint investigation

   10 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Apr 20, 2026
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Apr 20, 2026
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Apr 20, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 20, 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 Apr 20, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 20, 2026

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

4. Sep 172025

   Complaint investigation

   8 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 16, 2025
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Oct 16, 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 Oct 16, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Oct 16, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Oct 16, 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 Oct 16, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Oct 16, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 16, 2025

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

5. Jul 212025

   Standard health inspection

   9 findings

   The same visit included a complaint investigation.

   • 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 GActual harmCorrected Jul 30, 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 Jul 30, 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 Jul 30, 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 Jul 30, 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 30, 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 Jul 30, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 30, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Jul 30, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 30, 2025

   Enforcement Action

   Civil money penalty, $127,088 imposed July 21, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 21, 2025, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed July 21, 2025. Status: Closed, October 16, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 21, 2025, the nearest before the penalty date.

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

6. May 292025

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 11, 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 11, 2025

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

7. Apr 32025

   Complaint investigation

   4 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jun 11, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 11, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Apr 22, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Apr 22, 2025

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

8. Sep 192024

   Standard health inspection

   4 findings

   The same visit included a complaint investigation.

   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Oct 9, 2024
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level ENo actual harm, potential for moreCorrected Oct 9, 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 Oct 9, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 9, 2024

   Enforcement Action

   Civil money penalty, $22,588 imposed September 19, 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 September 19, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 3, 2025. Status: Closed, June 11, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 19, 2024, the nearest before the penalty date.

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

9. Aug 182024

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Sep 4, 2024

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

10. Jun 272024

    Complaint investigation

    3 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Sep 4, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jul 24, 2024
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Jul 24, 2024

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

11. May 32024

    Complaint investigation

    3 findings

    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 17, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 17, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 17, 2024

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

12. Feb 272024

    Complaint investigation

    6 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Mar 20, 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 20, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 20, 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 Mar 20, 2024
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 20, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 20, 2024

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

13. Jan 102024

    Complaint investigation

    1 finding

    • 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 Jan 18, 2024

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

14. Oct 92023

    Complaint investigation

    5 findings

    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Oct 25, 2023
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Oct 25, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 9, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 25, 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 DNo actual harm, potential for moreCorrected Oct 9, 2023

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

15. Jun 292023

    Standard health inspection

    17 findings

    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 29, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jul 29, 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 Oct 25, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 29, 2023
    • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Jul 29, 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 Jul 29, 2023
    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Jul 29, 2023
    • 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 29, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 29, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 29, 2023
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jul 29, 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 DNo actual harm, potential for moreCorrected Aug 23, 2023
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Oct 25, 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 DNo actual harm, potential for moreCorrected Jul 29, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 23, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jul 29, 2023
    • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level CPotential for minimal harmCorrected Jul 29, 2023

    Enforcement Action

    Civil money penalty, $53,077 imposed February 27, 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 June 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $55,424 imposed June 27, 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 June 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed June 27, 2024. Status: Closed, September 4, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 29, 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

   Infection Control, Cited in Eight Inspections

   Inspectors cited F880 in June 2023, October 2023, February 2024, September 2024, July 2025, September 2025, February 2026 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252525262626F880 across all 15 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Seven Inspections

   Inspectors cited F689 in June 2023, October 2023, February 2024, April 2025, May 2025, February 2026 and June 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.

   232324242424242425252525262626F689 across all 15 inspections, oldest to newest
3. 3

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in June 2023, April 2025, May 2025, July 2025, February 2026 and June 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252525262626F684 across all 15 inspections, oldest to newest
4. 4

   Dignity and Resident Rights, Cited in Four Inspections

   Inspectors cited F550 in June 2023, January 2024, May 2024 and February 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.

   232324242424242425252525262626F550 across all 15 inspections, oldest to newest
5. 5

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in February 2024, June 2024, August 2024 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

   232324242424242425252525262626F686 across all 15 inspections, oldest to newest
6. 6

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in February 2024, September 2024, February 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.

   232324242424242425252525262626F842 across all 15 inspections, oldest to newest
7. 7

   Telling Families About Changes, Cited in Three Inspections

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

   232324242424242425252525262626F580 across all 15 inspections, oldest to newest
8. 8

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in June 2023, February 2024 and July 2025. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252525262626F656 across all 15 inspections, oldest to newest
9. 9

   Professional Standards, Cited in Three Inspections

   Inspectors cited F658 in February 2024, May 2024 and September 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.

   232324242424242425252525262626F658 across all 15 inspections, oldest to newest
10. 10

    Continence and Catheter Care, Cited in Three Inspections

    Inspectors cited F690 in June 2023, October 2023 and September 2025. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

    232324242424242425252525262626F690 across all 15 inspections, oldest to newest
11. 11

    Treatment Choices and Advance Directives, Cited in Two Inspections

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

    232324242424242425252525262626F578 across all 15 inspections, oldest to newest
12. 12

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in June 2023 and July 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.

    232324242424242425252525262626F584 across all 15 inspections, oldest to newest
13. 13

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in June 2023 and July 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.

    232324242424242425252525262626F657 across all 15 inspections, oldest to newest
14. 14

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in June 2023 and May 2024. 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.

    232324242424242425252525262626F677 across all 15 inspections, oldest to newest
15. 15

    Mobility and Range of Motion, Cited in Two Inspections

    Inspectors cited F688 in June 2023 and July 2025. This citation covers care that keeps or improves a resident’s movement and mobility. 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.

    232324242424242425252525262626F688 across all 15 inspections, oldest to newest
16. 16

    Citation F865, Cited in Two Inspections

    Inspectors cited F865 in September 2025 and February 2026. The agency describes it this way: Have a plan that describes the process for conducting QAPI and QAA activities. 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.

    232324242424242425252525262626F865 across all 15 inspections, oldest to newest
17. 17

    Nursing Staff Levels, No Recorded Correction

    F725 was cited in June 2023, October 2023, June 2024, April 2025, July 2025, September 2025, February 2026 and August 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. The most serious was level F (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242425252525262626F725 across all 15 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

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

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

2. 02

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

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

3. 03

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

   Quality of Care: cited in six inspections, most seriously at level G.

4. 04

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

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

5. 05

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

   Pressure Injury Care: cited in four inspections, most seriously at level J.

6. 06

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

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

7. 07

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

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

8. 08

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

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

9. 09

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

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

10. 10

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

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

11. 11

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

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

12. 12

    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.

13. 13

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

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

14. 14

    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 E.

15. 15

    What do you do to keep residents moving, and who provides range-of-motion care?

    Mobility and Range of Motion: cited in two inspections, most seriously at level G.

16. 16

    What changed after F865 was cited, and how do you check it now?

    Citation F865: cited in two inspections, most seriously at level F.

17. 17

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

    Nursing Staff Levels: cited in eight inspections, most seriously at level F. The August 13, 2026 citation has no recorded correction date.

18. 18

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

    A $127,088 civil money penalty was imposed July 21, 2025. CMS publishes the fine, not whether it has been paid. The record holds seven enforcement actions in the window.

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

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

  Iowa state survey agency

  Inspection Jun 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)

  Iowa state survey agency

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

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

  Iowa state survey agency

  Inspection Jan 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)

  Iowa state survey agency

  Inspection Feb 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)

  Iowa state survey agency

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

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

  Iowa state survey agency

  Inspection Jun 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)

  Iowa state survey agency

  Inspection Aug 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Iowa state survey agency

  Inspection Sep 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)

  Iowa state survey agency

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

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

  Iowa state survey agency

  Inspection May 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Iowa state survey agency

  Inspection Jul 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Iowa state survey agency

  Inspection Sep 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Iowa state survey agency

  Inspection Feb 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Iowa state survey agency

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

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

  Iowa state survey agency

  Inspection Aug 13, 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 · 165448

  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.