The Vardell Report.Oakland Nursing & Rehabilitation Center

Across 4 inspections from March 2019 to December 2025, state surveyors documented 72 findings at Oakland Nursing & Rehabilitation Center; 72 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

4

2019–2025, standard and complaint

Findings

72

Deficiencies cited by state inspectors

Corrected

72

Of 72 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

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. Dec 122025

   Standard health inspection

   25 findings

   The same visit included a complaint investigation.

   • 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 FNo actual harm, potential for moreCorrected Feb 4, 2026
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Feb 4, 2026
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Feb 4, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Apr 1, 2026
   • 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 Feb 4, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Feb 4, 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 Feb 4, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • 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 Feb 4, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • 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 Feb 4, 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 Feb 4, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • 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 Feb 4, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • 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 Feb 4, 2026
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • 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 Feb 4, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Feb 4, 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 Feb 4, 2026

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

2. Aug 12025

   Complaint investigation

   5 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jul 28, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Aug 25, 2025
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Aug 25, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 25, 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 Aug 25, 2025

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

3. Jun 72023

   Standard health inspection

   26 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 Jul 17, 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 Jul 17, 2023
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • 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 17, 2023
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • 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 Jul 17, 2023
   • 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 Jul 17, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 17, 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 Jul 17, 2023
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • 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 Jul 17, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 17, 2023
   • 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 Jul 17, 2023

   Enforcement Action

   Civil money penalty, $8,278 imposed August 1, 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 June 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $8,281 imposed August 1, 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 June 7, 2023, the nearest before the penalty date.

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

4. Mar 152019

   Standard health inspection

   16 findings

   • 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 Apr 22, 2019
   • 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 22, 2019
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Apr 22, 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 Apr 22, 2019
   • 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 Apr 22, 2019
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Apr 22, 2019
   • 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 Apr 22, 2019
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 22, 2019
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 22, 2019
   • 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 Apr 22, 2019
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 22, 2019
   • 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 Apr 22, 2019
   • 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 22, 2019
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level CPotential for minimal harmCorrected Apr 22, 2019
   • 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 BPotential for minimal harmCorrected Apr 22, 2019
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level BPotential for minimal harmCorrected Apr 22, 2019

   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

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in March 2019, June 2023 and December 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19232525F550 across all 4 inspections, oldest to newest
2. 2

   Accurate Assessments, Cited in Three Inspections

   Inspectors cited F641 in March 2019, June 2023 and December 2025. This citation covers whether each resident’s assessment correctly records their condition. 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.

   19232525F641 across all 4 inspections, oldest to newest
3. 3

   Medical Records, Cited in Three Inspections

   Inspectors cited F842 in March 2019, June 2023 and December 2025. 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.

   19232525F842 across all 4 inspections, oldest to newest
4. 4

   Citation F561, Cited in Two Inspections

   Inspectors cited F561 in March 2019 and June 2023. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 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.

   19232525F561 across all 4 inspections, oldest to newest
5. 5

   Telling Families About Changes, Cited in Two Inspections

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

   19232525F580 across all 4 inspections, oldest to newest
6. 6

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in March 2019 and June 2023. 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.

   19232525F623 across all 4 inspections, oldest to newest
7. 7

   Citation F625, Cited in Two Inspections

   Inspectors cited F625 in March 2019 and June 2023. The agency describes it this way: Notify 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. 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.

   19232525F625 across all 4 inspections, oldest to newest
8. 8

   The First 48 Hours, Cited in Two Inspections

   Inspectors cited F655 in March 2019 and December 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

   19232525F655 across all 4 inspections, oldest to newest
9. 9

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in March 2019 and December 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19232525F656 across all 4 inspections, oldest to newest
10. 10

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in June 2023 and December 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F677 across all 4 inspections, oldest to newest
11. 11

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in June 2023 and December 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F684 across all 4 inspections, oldest to newest
12. 12

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in June 2023 and August 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 J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F689 across all 4 inspections, oldest to newest
13. 13

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in June 2023 and August 2025. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F692 across all 4 inspections, oldest to newest
14. 14

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in March 2019 and December 2025. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such 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.

    19232525F697 across all 4 inspections, oldest to newest
15. 15

    Citation F711, Cited in Two Inspections

    Inspectors cited F711 in March 2019 and June 2023. 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.

    19232525F711 across all 4 inspections, oldest to newest
16. 16

    Citation F712, Cited in Two Inspections

    Inspectors cited F712 in June 2023 and December 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F712 across all 4 inspections, oldest to newest
17. 17

    Citation F726, Cited in Two Inspections

    Inspectors cited F726 in March 2019 and December 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. 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.

    19232525F726 across all 4 inspections, oldest to newest
18. 18

    Citation F727, Cited in Two Inspections

    Inspectors cited F727 in June 2023 and December 2025. 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.

    19232525F727 across all 4 inspections, oldest to newest
19. 19

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in June 2023 and December 2025. This citation covers how drugs are labeled and kept locked, including controlled 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.

    19232525F761 across all 4 inspections, oldest to newest
20. 20

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in March 2019 and December 2025. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. 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.

    19232525F867 across all 4 inspections, oldest to newest
21. 21

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in June 2023 and December 2025. 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 F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232525F921 across all 4 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 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 E.

2. 02

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

   Accurate Assessments: cited in three inspections, most seriously at level D.

3. 03

   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.

4. 04

   What changed after F561 was cited, and how do you check it now?

   Citation F561: cited in two inspections, most seriously at level D.

5. 05

   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.

6. 06

   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.

7. 07

   What changed after F625 was cited, and how do you check it now?

   Citation F625: cited in two inspections, most seriously at level D.

8. 08

   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 D.

9. 09

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

   Care Plans: cited in two inspections, most seriously at level E.

10. 10

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

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

11. 11

    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 two inspections, most seriously at level D.

12. 12

    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 J.

13. 13

    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 G.

14. 14

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

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

15. 15

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

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

16. 16

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

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

17. 17

    What changed after F726 was cited, and how do you check it now?

    Citation F726: cited in two inspections, most seriously at level F.

18. 18

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

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

19. 19

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

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

20. 20

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

21. 21

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

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

22. 22

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

    Insufficient nursing staff was cited in March 2019.

23. 23

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

    An $8,278 civil money penalty was imposed August 1, 2025. CMS publishes the fine, not whether it has been paid. The record holds two 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 Mar 15, 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 7, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Aug 1, 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 Dec 12, 2025 · 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 · 215232

  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.