The Vardell Report.Axiom Healthcare of Mount Vernon

Across 14 inspections from October 2022 to August 2026, state surveyors documented 70 findings at Axiom Healthcare of Mount Vernon; 64 have a recorded correction and 6 await one; CMS lists 11 enforcement actions in the window.

Inspections

14

2022–2026, complaint and standard

Findings

70

Deficiencies cited by state inspectors

Corrected

64

Of 70 findings, with a recorded correction date

Penalties

11

7 fines; payment not published, 4 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 282026

   Complaint investigation

   6 findings

   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level JImmediate jeopardyDeficient, Provider has no plan of correction
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmDeficient, Provider has no plan of correction
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmDeficient, Provider has no plan of correction
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F760Ensure that residents are free from significant medication errors.Level DNo 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. Apr 72026

   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 Apr 8, 2026
   • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level GActual harmCorrected Apr 8, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 8, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 8, 2026

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

3. Dec 182025

   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 FNo actual harm, potential for moreCorrected Feb 12, 2026

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

4. Apr 22025

   Complaint investigation

   2 findings

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 30, 2025
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Apr 30, 2025

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

5. Mar 252025

   Complaint investigation

   20 findings

   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level KImmediate jeopardyCorrected Apr 23, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Apr 24, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level JImmediate jeopardyCorrected Oct 31, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 23, 2025
   • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level FNo actual harm, potential for moreCorrected May 8, 2025
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level FNo actual harm, potential for moreCorrected May 21, 2025
   • F713Provide or arrange emergency care by a doctor 24 hours a day.Level FNo actual harm, potential for moreCorrected Apr 19, 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 FNo actual harm, potential for moreCorrected Apr 18, 2025
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level FNo actual harm, potential for moreCorrected May 14, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Apr 18, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Apr 28, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Apr 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 May 13, 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 May 7, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 18, 2025

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

6. Dec 192024

   Standard health inspection

   14 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jan 15, 2025
   • 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 Jan 15, 2025
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level FNo actual harm, potential for moreCorrected May 14, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 14, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Jan 15, 2025
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 23, 2025
   • 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 May 27, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • 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 Jan 15, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 18, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 30, 2025

   Enforcement Action

   Civil money penalty, $230,169 imposed December 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 December 19, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed December 19, 2024. Status: Closed, May 27, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 19, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $53,092 imposed December 18, 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 December 19, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed December 18, 2025. Status: Closed, March 19, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 19, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $15,520 imposed April 7, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 19, 2024, the nearest before the penalty date.

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

7. Aug 52024

   Complaint investigation

   2 findings

   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level FNo actual harm, potential for moreCorrected Aug 28, 2024
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level FNo actual harm, potential for moreCorrected Aug 28, 2024

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

8. May 312024

   Complaint investigation

   4 findings

   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level FNo actual harm, potential for moreCorrected Aug 28, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 24, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 24, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jun 24, 2024

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

9. May 152024

   Complaint investigation

   2 findings

   • 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 May 28, 2024
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jun 1, 2024

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

10. Mar 122024

    Complaint investigation

    1 finding

    • 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 Mar 19, 2024

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

11. Jan 112024

    Complaint investigation

    1 finding

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jan 23, 2024

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

12. Jan 52024

    Complaint investigation

    2 findings

    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jan 16, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 16, 2024

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

13. Nov 212023

    Standard health inspection

    6 findings

    • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level JImmediate jeopardyCorrected Dec 11, 2023
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Dec 11, 2023
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Dec 11, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 11, 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 Dec 11, 2023
    • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level DNo actual harm, potential for moreCorrected Dec 11, 2023

    Enforcement Action

    Civil money penalty, $7,443 imposed November 21, 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 November 21, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $7,446 imposed November 21, 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 November 21, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed November 21, 2023. Status: Closed, December 29, 2023. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 21, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $8,824 imposed January 5, 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 November 21, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $8,824 imposed January 5, 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 November 21, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed May 15, 2024. Status: Closed, August 28, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 21, 2023, the nearest before the penalty date.

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

14. Oct 142022

    Standard health inspection

    5 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 4, 2022
    • F638Assure that each resident’s assessment is updated at least once every 3 months.Level ENo actual harm, potential for moreCorrected Nov 4, 2022
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Nov 4, 2022
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Nov 4, 2022
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 4, 2022

    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

   Citation F803, Cited in Three Inspections

   Inspectors cited F803 in November 2023, December 2024 and March 2025. The agency describes it this way: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 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.

   2223242424242424242525252626F803 across all 14 inspections, oldest to newest
2. 2

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in October 2022, November 2023 and December 2024. This citation covers how food is stored, prepared and served. 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.

   2223242424242424242525252626F812 across all 14 inspections, oldest to newest
3. 3

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in October 2022, December 2024 and April 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.

   2223242424242424242525252626F880 across all 14 inspections, oldest to newest
4. 4

   Investigating Alleged Violations, Cited in Two Inspections

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

   2223242424242424242525252626F610 across all 14 inspections, oldest to newest
5. 5

   Help With Daily Living, Cited in Two Inspections

   Inspectors cited F677 in December 2024 and March 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223242424242424242525252626F677 across all 14 inspections, oldest to newest
6. 6

   Accident Hazards and Supervision, Cited in Two Inspections

   Inspectors cited F689 in November 2023 and March 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.

   2223242424242424242525252626F689 across all 14 inspections, oldest to newest
7. 7

   Dialysis Care, Cited in Two Inspections

   Inspectors cited F698 in December 2024 and March 2025. This citation covers care for residents who need dialysis. 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.

   2223242424242424242525252626F698 across all 14 inspections, oldest to newest
8. 8

   Citation F712, Cited in Two Inspections

   Inspectors cited F712 in May 2024 and March 2025. The agency describes it this way: Ensure that the resident and his/her doctor meet face-to-face at all required visits. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223242424242424242525252626F712 across all 14 inspections, oldest to newest
9. 9

   Nursing Staff Levels, Cited in Two Inspections

   Inspectors cited F725 in March 2025 and December 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. 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.

   2223242424242424242525252626F725 across all 14 inspections, oldest to newest
10. 10

    Citation F727, Cited in Two Inspections

    Inspectors cited F727 in May 2024 and December 2024. The agency describes it this way: Have 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. 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.

    2223242424242424242525252626F727 across all 14 inspections, oldest to newest
11. 11

    Psychotropic Medications, Cited in Two Inspections

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

    2223242424242424242525252626F758 across all 14 inspections, oldest to newest
12. 12

    Citation F809, Cited in Two Inspections

    Inspectors cited F809 in May 2024 and August 2024. The agency describes it this way: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. 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.

    2223242424242424242525252626F809 across all 14 inspections, oldest to newest
13. 13

    Citation F605, No Recorded Correction

    F605 was cited in August 2026. The agency describes it this way: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. The most serious was level J (immediate jeopardy). 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.

    2223242424242424242525252626F605 across all 14 inspections, oldest to newest
14. 14

    Quality of Care, No Recorded Correction

    F684 was cited in January 2024, March 2025 and August 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious was level J (immediate jeopardy). 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.

    2223242424242424242525252626F684 across all 14 inspections, oldest to newest
15. 15

    Pressure Injury Care, No Recorded Correction

    F686 was cited in January 2024, May 2024, December 2024 and August 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious was level G (actual harm). 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.

    2223242424242424242525252626F686 across all 14 inspections, oldest to newest
16. 16

    Nutrition and Hydration, No Recorded Correction

    F692 was cited in January 2024, May 2024 and August 2026. This citation covers whether residents get enough food and fluids to stay healthy. The most serious was level G (actual harm). 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.

    2223242424242424242525252626F692 across all 14 inspections, oldest to newest
17. 17

    Significant Medication Errors, No Recorded Correction

    F760 was cited in December 2024, March 2025 and August 2026. This citation covers whether residents are free from significant medication errors. The most serious was level D (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.

    2223242424242424242525252626F760 across all 14 inspections, oldest to newest
18. 18

    Citation F940, No Recorded Correction

    F940 was cited in August 2026. The agency describes it this way: Develop, implement, and/or maintain an effective training program for all new and existing staff members. 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.

    2223242424242424242525252626F940 across all 14 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

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

   Citation F803: cited in three inspections, most seriously at level J.

2. 02

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

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

3. 03

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

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

4. 04

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

   Investigating Alleged Violations: cited in two inspections, most seriously at level D.

5. 05

   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.

6. 06

   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 two inspections, most seriously at level G.

7. 07

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

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

8. 08

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

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

9. 09

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

   Nursing Staff Levels: cited in two inspections, most seriously at level F.

10. 10

    What changed after F727 was cited, and how do you check it now?

    Citation F727: cited in two inspections, most seriously at level F.

11. 11

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

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

12. 12

    What changed after F809 was cited, and how do you check it now?

    Citation F809: cited in two inspections, most seriously at level F.

13. 13

    What changed after F605 was cited, and how do you check it now?

    Citation F605: cited in one inspections, most seriously at level J. The August 28, 2026 citation has no recorded correction date.

14. 14

    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 three inspections, most seriously at level J. The August 28, 2026 citation has no recorded correction date.

15. 15

    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 G. The August 28, 2026 citation has no recorded correction date.

16. 16

    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. The August 28, 2026 citation has no recorded correction date.

17. 17

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

    Significant Medication Errors: cited in three inspections, most seriously at level D. The August 28, 2026 citation has no recorded correction date.

18. 18

    What changed after F940 was cited, and how do you check it now?

    Citation F940: cited in one inspections, most seriously at level F. The August 28, 2026 citation has no recorded correction date.

19. 19

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

    A $15,520 civil money penalty was imposed April 7, 2026. CMS publishes the fine, not whether it has been paid. The record holds 11 enforcement actions in the window.

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

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

  Illinois state survey agency

  Inspection Oct 14, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Nov 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jan 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jan 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)

  Illinois state survey agency

  Inspection Mar 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)

  Illinois state survey agency

  Inspection May 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois 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)

  Illinois state survey agency

  Inspection Aug 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 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)

  Illinois state survey agency

  Inspection Mar 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Apr 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Apr 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Aug 28, 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 · 145517

  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.