The Vardell Report.Autumn Lake Healthcare at Birch Manor

Across 6 inspections from August 2018 to July 2026, state surveyors documented 87 findings at Autumn Lake Healthcare at Birch Manor; 85 have a recorded correction and 2 await one; CMS lists no enforcement action in the window.

Inspections

6

2018–2026, complaint and standard

Findings

87

Deficiencies cited by state inspectors

Corrected

85

Of 87 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

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. Jul 162026

   Complaint investigation

   2 findings

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction

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

2. Nov 202025

   Complaint investigation

   1 finding

   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Jan 5, 2026

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

3. Jun 112025

   Standard health inspection

   22 findings

   The same visit included a complaint investigation.

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level FNo actual harm, potential for moreCorrected Jul 15, 2025
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Jul 15, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 15, 2025
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Jul 15, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 15, 2025
   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Jul 15, 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 15, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 15, 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 15, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 15, 2025
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jul 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 DNo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 15, 2025
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Jul 15, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Jul 15, 2025
   • F906Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.Level DNo actual harm, potential for moreCorrected Jul 15, 2025

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

4. Nov 42024

   Complaint investigation

   2 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 Dec 6, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 6, 2024

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

5. Jun 92021

   Standard health inspection

   22 findings

   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Aug 6, 2021
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 Aug 6, 2021
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 Aug 6, 2021
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 Aug 6, 2021
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 6, 2021
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 Aug 6, 2021
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • 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 6, 2021
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F923Have enough outside ventilation via a window or mechanical ventilation, or both.Level DNo actual harm, potential for moreCorrected Aug 6, 2021
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Aug 6, 2021

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

6. Aug 32018

   Standard health inspection

   38 findings

   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel FNo actual harm, potential for moreCorrected Oct 8, 2018
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level FNo actual harm, potential for moreCorrected Oct 8, 2018
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level FNo actual harm, potential for moreCorrected Oct 8, 2018
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level FNo actual harm, potential for moreCorrected Oct 8, 2018
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • 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 Oct 8, 2018
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Oct 8, 2018
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Oct 8, 2018
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Oct 8, 2018
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Oct 8, 2018
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Oct 8, 2018
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 8, 2018
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F642Ensure a qualified health professional conducts resident assessments.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • 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 8, 2018
   • 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 8, 2018
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 Oct 8, 2018
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Oct 8, 2018
   • 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 CPotential for minimal harmCorrected Oct 8, 2018
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Oct 8, 2018
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level CPotential for minimal harmCorrected Oct 8, 2018

   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

   A Clean, Homelike Setting, Cited in Four Inspections

   Inspectors cited F584 in August 2018, June 2021, November 2024 and June 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.

   182124252526F584 across all 6 inspections, oldest to newest
2. 2

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in August 2018, June 2021 and June 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 F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   182124252526F657 across all 6 inspections, oldest to newest
3. 3

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in August 2018, June 2021 and June 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   182124252526F684 across all 6 inspections, oldest to newest
4. 4

   Medical Records, Cited in Three Inspections

   Inspectors cited F842 in August 2018, June 2021 and June 2025. This citation covers whether resident records are complete, accurate and kept confidential. 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.

   182124252526F842 across all 6 inspections, oldest to newest
5. 5

   Citation F568, Cited in Two Inspections

   Inspectors cited F568 in August 2018 and June 2025. The agency describes it this way: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. 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.

   182124252526F568 across all 6 inspections, oldest to newest
6. 6

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in August 2018 and June 2021. 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.

   182124252526F580 across all 6 inspections, oldest to newest
7. 7

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in August 2018 and June 2025. 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.

   182124252526F610 across all 6 inspections, oldest to newest
8. 8

   Citation F622, Cited in Two Inspections

   Inspectors cited F622 in August 2018 and June 2021. The agency describes it this way: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. 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.

   182124252526F622 across all 6 inspections, oldest to newest
9. 9

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in August 2018 and June 2021. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. 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.

   182124252526F623 across all 6 inspections, oldest to newest
10. 10

    Citation F624, Cited in Two Inspections

    Inspectors cited F624 in August 2018 and June 2021. The agency describes it this way: Prepare residents for a safe transfer or discharge from the nursing home. 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.

    182124252526F624 across all 6 inspections, oldest to newest
11. 11

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in August 2018 and June 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    182124252526F641 across all 6 inspections, oldest to newest
12. 12

    The First 48 Hours, Cited in Two Inspections

    Inspectors cited F655 in August 2018 and June 2021. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

    182124252526F655 across all 6 inspections, oldest to newest
13. 13

    Provide activities to meet all resident's needs, Cited in Two Inspections

    Inspectors cited F679 in August 2018 and June 2025. The agency describes it this way: Provide activities to meet all resident's needs. 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.

    182124252526F679 across all 6 inspections, oldest to newest
14. 14

    Mobility and Range of Motion, Cited in Two Inspections

    Inspectors cited F688 in August 2018 and June 2021. This citation covers care that keeps or improves a resident’s movement and mobility. 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.

    182124252526F688 across all 6 inspections, oldest to newest
15. 15

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in August 2018 and June 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. 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.

    182124252526F689 across all 6 inspections, oldest to newest
16. 16

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in August 2018 and June 2021. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    182124252526F692 across all 6 inspections, oldest to newest
17. 17

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in August 2018 and June 2021. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. 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.

    182124252526F757 across all 6 inspections, oldest to newest
18. 18

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in August 2018 and June 2021. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    182124252526F761 across all 6 inspections, oldest to newest
19. 19

    Citation F806, Cited in Two Inspections

    Inspectors cited F806 in August 2018 and June 2021. 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.

    182124252526F806 across all 6 inspections, oldest to newest
20. 20

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in August 2018 and June 2025. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    182124252526F812 across all 6 inspections, oldest to newest
21. 21

    Citation F868, Cited in Two Inspections

    Inspectors cited F868 in August 2018 and June 2025. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. 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.

    182124252526F868 across all 6 inspections, oldest to newest
22. 22

    Reporting Suspected Abuse, No Recorded Correction

    F609 was cited in August 2018, November 2024, June 2025 and July 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. The most serious was level D (no actual harm, potential for more). The July 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.

    182124252526F609 across all 6 inspections, oldest to newest
23. 23

    Care Plans, No Recorded Correction

    F656 was cited in August 2018, June 2021, June 2025 and July 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious was level F (no actual harm, potential for more). The July 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.

    182124252526F656 across all 6 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 was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in four inspections, most seriously at level E.

2. 02

   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 F.

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 three inspections, most seriously at level E.

4. 04

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

   Medical Records: cited in three inspections, most seriously at level F.

5. 05

   What changed after F568 was cited, and how do you check it now?

   Citation F568: cited in two inspections, most seriously at level D.

6. 06

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

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

7. 07

   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.

8. 08

   What changed after F622 was cited, and how do you check it now?

   Citation F622: cited in two inspections, most seriously at level D.

9. 09

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.

10. 10

    What changed after F624 was cited, and how do you check it now?

    Citation F624: cited in two inspections, most seriously at level D.

11. 11

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

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

12. 12

    What happens in the first 48 hours after admission, and who writes the first care plan?

    The First 48 Hours: cited in two inspections, most seriously at level F.

13. 13

    What changed after F679 was cited, and how do you check it now?

    Provide activities to meet all resident's needs: cited in two inspections, most seriously at level E.

14. 14

    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 D.

15. 15

    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 D.

16. 16

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

    Nutrition and Hydration: cited in two inspections, most seriously at level D.

17. 17

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

18. 18

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

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

19. 19

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

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

20. 20

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

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

21. 21

    What changed after F868 was cited, and how do you check it now?

    Citation F868: cited in two inspections, most seriously at level E.

22. 22

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

    Reporting Suspected Abuse: cited in four inspections, most seriously at level D. The July 16, 2026 citation has no recorded correction date.

23. 23

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

    Care Plans: cited in four inspections, most seriously at level F. The July 16, 2026 citation has no recorded correction date.

24. 24

    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.

25. 25

    Has the home been fined or had payments denied before this record begins?

    CMS lists no fines or payment denials in this window. The record starts August 3, 2018; anything earlier is not in it.

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

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

  Maryland state survey agency

  Inspection Aug 3, 2018 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Jun 9, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Nov 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Jun 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)

  Maryland state survey agency

  Inspection Nov 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)

  Maryland state survey agency

  Inspection Jul 16, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 215136

  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.