The Vardell Report.Layhill Nursing and Rehabilitation Center

Across 6 inspections from September 2019 to July 2026, state surveyors documented 105 findings at Layhill Nursing and Rehabilitation Center; 105 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

6

2019–2026, complaint and standard

Findings

105

Deficiencies cited by state inspectors

Corrected

105

Of 105 findings, with a recorded correction date

Penalties

3

2 fines; payment not published, 1 closed

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

1. Jul 142026

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 21, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 21, 2026

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

2. Feb 182026

   Standard health inspection

   15 findings

   The same visit included a complaint investigation.

   • 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 Apr 3, 2026
   • F567Honor the resident's right to manage his or her financial affairs.Level ENo actual harm, potential for moreCorrected Apr 3, 2026
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level ENo actual harm, potential for moreCorrected Apr 3, 2026
   • F917Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Level ENo actual harm, potential for moreCorrected Apr 3, 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 3, 2026
   • 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 Apr 3, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • 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 Apr 3, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 3, 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 3, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Apr 3, 2026

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

3. Oct 92025

   Complaint investigation

   11 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Sep 6, 2025
   • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level ENo actual harm, potential for moreCorrected Dec 10, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Dec 10, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Dec 10, 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 Dec 10, 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 Dec 10, 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 Dec 10, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Dec 10, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 10, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 10, 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 Dec 10, 2025

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

4. Sep 232024

   Standard health inspection

   46 findings

   The same visit included a complaint investigation.

   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level KImmediate jeopardyCorrected Nov 18, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level FNo actual harm, potential for moreCorrected Nov 18, 2024
   • F732Post nurse staffing information every day.Level FNo actual harm, potential for moreCorrected Nov 18, 2024
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Nov 18, 2024
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 Nov 18, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jan 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 Nov 18, 2024
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected Jan 15, 2025
   • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level ENo actual harm, potential for moreCorrected Nov 18, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 Nov 18, 2024
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 Nov 18, 2024
   • 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 Nov 18, 2024
   • 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 Nov 18, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 Nov 18, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • 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 Nov 18, 2024
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Nov 18, 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 Nov 18, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Nov 18, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Jan 15, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jan 15, 2025

   Enforcement Action

   Civil money penalty, $100,523 imposed September 23, 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 23, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed September 23, 2024. Status: Closed, January 21, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 23, 2024, the nearest before the penalty date.

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

5. Jun 182024

   Complaint investigation

   24 findings

   • F583Keep residents' personal and medical records private and confidential.Level GActual harmCorrected Jul 26, 2024
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jul 26, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Jul 26, 2024
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Jul 26, 2024
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jul 26, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 26, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • 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 26, 2024
   • 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 Jul 26, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • 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 Jul 26, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jul 26, 2024
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Jul 26, 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 Jul 26, 2024
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level DNo actual harm, potential for moreCorrected Jul 26, 2024

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

6. Sep 272019

   Standard health inspection

   7 findings

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 10, 2019
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Nov 10, 2019
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Nov 10, 2019
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Nov 10, 2019
   • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level DNo actual harm, potential for moreCorrected Nov 10, 2019
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 10, 2019
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 10, 2019

   Enforcement Action

   Civil money penalty, $53,073 imposed June 18, 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 27, 2019, the nearest before the penalty date.

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

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

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

1. 1

   Care Plans, Cited in Four Inspections

   Inspectors cited F656 in September 2019, June 2024, September 2024 and February 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192424252626F656 across all 6 inspections, oldest to newest
2. 2

   Professional Standards, Cited in Four Inspections

   Inspectors cited F658 in September 2019, September 2024, October 2025 and February 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

   192424252626F658 across all 6 inspections, oldest to newest
3. 3

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in September 2019, June 2024, September 2024 and October 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. 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.

   192424252626F689 across all 6 inspections, oldest to newest
4. 4

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in September 2019, June 2024 and February 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192424252626F550 across all 6 inspections, oldest to newest
5. 5

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in September 2019, June 2024 and October 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192424252626F609 across all 6 inspections, oldest to newest
6. 6

   Care Plan Timing and Review, Cited in Three Inspections

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

   192424252626F657 across all 6 inspections, oldest to newest
7. 7

   Quality of Care, Cited in Three Inspections

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

   192424252626F684 across all 6 inspections, oldest to newest
8. 8

   Pressure Injury Care, Cited in Three Inspections

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

   192424252626F686 across all 6 inspections, oldest to newest
9. 9

   Medical Records, Cited in Three Inspections

   Inspectors cited F842 in June 2024, September 2024 and February 2026. This citation covers whether resident records are complete, accurate and kept confidential. 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.

   192424252626F842 across all 6 inspections, oldest to newest
10. 10

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in September 2019, September 2024 and February 2026. 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.

    192424252626F880 across all 6 inspections, oldest to newest
11. 11

    Citation F552, Cited in Two Inspections

    Inspectors cited F552 in September 2024 and October 2025. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252626F552 across all 6 inspections, oldest to newest
12. 12

    Treatment Choices and Advance Directives, Cited in Two Inspections

    Inspectors cited F578 in June 2024 and September 2024. 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.

    192424252626F578 across all 6 inspections, oldest to newest
13. 13

    Telling Families About Changes, Cited in Two Inspections

    Inspectors cited F580 in June 2024 and September 2024. 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.

    192424252626F580 across all 6 inspections, oldest to newest
14. 14

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in September 2024 and February 2026. 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.

    192424252626F584 across all 6 inspections, oldest to newest
15. 15

    Investigating Alleged Violations, Cited in Two Inspections

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

    192424252626F610 across all 6 inspections, oldest to newest
16. 16

    Citation F622, Cited in Two Inspections

    Inspectors cited F622 in June 2024 and September 2024. 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.

    192424252626F622 across all 6 inspections, oldest to newest
17. 17

    Citation F628, Cited in Two Inspections

    Inspectors cited F628 in October 2025 and February 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252626F628 across all 6 inspections, oldest to newest
18. 18

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in June 2024 and September 2024. 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.

    192424252626F641 across all 6 inspections, oldest to newest
19. 19

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in June 2024 and September 2024. 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.

    192424252626F692 across all 6 inspections, oldest to newest
20. 20

    Citation F697, Cited in Two Inspections

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

    192424252626F697 across all 6 inspections, oldest to newest
21. 21

    Citation F711, Cited in Two Inspections

    Inspectors cited F711 in June 2024 and October 2025. The agency describes it this way: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. 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.

    192424252626F711 across all 6 inspections, oldest to newest
22. 22

    Citation F740, Cited in Two Inspections

    Inspectors cited F740 in June 2024 and September 2024. The agency describes it this way: Ensure each resident must receive and the facility must provide necessary behavioral health care and services. 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.

    192424252626F740 across all 6 inspections, oldest to newest
23. 23

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in September 2024 and February 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 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.

    192424252626F756 across all 6 inspections, oldest to newest
24. 24

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in September 2024 and February 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.

    192424252626F759 across all 6 inspections, oldest to newest
25. 25

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in September 2024 and February 2026. 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.

    192424252626F812 across all 6 inspections, oldest to newest
26. 26

    Citation F865, Cited in Two Inspections

    Inspectors cited F865 in June 2024 and September 2024. 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.

    192424252626F865 across all 6 inspections, oldest to newest
27. 27

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in September 2024 and February 2026. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252626F921 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

   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 E.

2. 02

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

   Professional Standards: cited in four inspections, most seriously at level E.

3. 03

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

   Accident Hazards and Supervision: cited in four inspections, most seriously at level E.

4. 04

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

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

5. 05

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

   Reporting Suspected Abuse: cited in three inspections, most seriously at level E.

6. 06

   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.

7. 07

   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.

8. 08

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

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

9. 09

   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 D.

10. 10

    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.

11. 11

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

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

12. 12

    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.

13. 13

    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 D.

14. 14

    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.

15. 15

    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 E.

16. 16

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

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

17. 17

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

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

18. 18

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

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

19. 19

    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.

20. 20

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

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

21. 21

    What changed after F711 was cited, and how do you check it now?

    Citation F711: cited in two inspections, most seriously at level E.

22. 22

    What changed after F740 was cited, and how do you check it now?

    Citation F740: cited in two inspections, most seriously at level D.

23. 23

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level D.

24. 24

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

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

25. 25

    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 F.

26. 26

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

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

27. 27

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

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

28. 28

    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.

29. 29

    What led to the 2024 fine, and has it been paid?

    A $100,523 civil money penalty was imposed September 23, 2024. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

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 Sep 27, 2019 · 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 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)

  Maryland state survey agency

  Inspection Sep 23, 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 Oct 9, 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 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)

  Maryland state survey agency

  Inspection Jul 14, 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 · 215168

  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.