The Vardell Report.Oakwood SNF LLC

Across 5 inspections from October 2019 to March 2026, state surveyors documented 88 findings at Oakwood SNF LLC; 88 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

5

2019–2026, standard and complaint

Findings

88

Deficiencies cited by state inspectors

Corrected

88

Of 88 findings, with a recorded correction date

Penalties

1

1 fine; 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. Mar 32026

   Standard health inspection

   32 findings

   • 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 ENo actual harm, potential for moreCorrected Apr 14, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 14, 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 14, 2026
   • 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 Apr 14, 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 Apr 14, 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 14, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 Apr 14, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Apr 14, 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 Apr 14, 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 Apr 14, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 Apr 14, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Apr 14, 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 Apr 14, 2026
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 Apr 14, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 Apr 14, 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 14, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • 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 Apr 14, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Apr 14, 2026

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

2. Feb 42026

   Complaint investigation

   6 findings

   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Mar 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 Mar 3, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 3, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 3, 2026
   • F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.Level DNo actual harm, potential for moreCorrected Mar 3, 2026
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Mar 3, 2026

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

3. Oct 92025

   Complaint investigation

   12 findings

   • 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 ENo actual harm, potential for moreCorrected Nov 24, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Nov 24, 2025
   • 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 24, 2025
   • 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 Nov 24, 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 Nov 24, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 24, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 24, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 24, 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 Nov 24, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Nov 24, 2025
   • 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 Nov 24, 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 Nov 24, 2025

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

4. Oct 212024

   Standard health inspection

   13 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jul 17, 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 Dec 9, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Dec 9, 2024
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Dec 9, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Dec 9, 2024
   • 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 Dec 9, 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 DNo actual harm, potential for moreCorrected Dec 9, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 9, 2024
   • 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 Dec 9, 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 Dec 9, 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 Dec 9, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 9, 2024
   • 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 Dec 9, 2024

   Enforcement Action

   Civil money penalty, $13,270 imposed October 21, 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 October 21, 2024, the nearest before the penalty date.

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

5. Oct 282019

   Standard health inspection

   25 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jan 22, 2020
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Jan 22, 2020
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 22, 2020
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Jan 22, 2020
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level ENo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 ENo actual harm, potential for moreCorrected Jan 22, 2020
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 Jan 22, 2020
   • 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 Jan 22, 2020
   • 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 Jan 22, 2020
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 Jan 22, 2020
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 Jan 22, 2020
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 Jan 22, 2020
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • 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 Jan 22, 2020
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jan 22, 2020
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jan 22, 2020

   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 Five Inspections

   Inspectors cited F584 in October 2019, October 2024, October 2025, February 2026 and March 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.

   1924252626F584 across all 5 inspections, oldest to newest
2. 2

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in October 2019, October 2024, October 2025 and March 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1924252626F842 across all 5 inspections, oldest to newest
3. 3

   Accurate Assessments, Cited in Three Inspections

   Inspectors cited F641 in October 2019, October 2024 and February 2026. 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.

   1924252626F641 across all 5 inspections, oldest to newest
4. 4

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in October 2019, October 2024 and March 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1924252626F657 across all 5 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in October 2019, October 2025 and March 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.

   1924252626F684 across all 5 inspections, oldest to newest
6. 6

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in October 2019, October 2024 and March 2026. 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.

   1924252626F761 across all 5 inspections, oldest to newest
7. 7

   Food Quality and Temperature, Cited in Three Inspections

   Inspectors cited F804 in October 2019, October 2025 and March 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

   1924252626F804 across all 5 inspections, oldest to newest
8. 8

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in October 2019, October 2024 and March 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.

   1924252626F880 across all 5 inspections, oldest to newest
9. 9

   Citation F561, Cited in Two Inspections

   Inspectors cited F561 in October 2025 and March 2026. 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.

   1924252626F561 across all 5 inspections, oldest to newest
10. 10

    Grievances, Cited in Two Inspections

    Inspectors cited F585 in October 2024 and October 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. 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.

    1924252626F585 across all 5 inspections, oldest to newest
11. 11

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in October 2019 and October 2024. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

    1924252626F600 across all 5 inspections, oldest to newest
12. 12

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in October 2019 and October 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.

    1924252626F610 across all 5 inspections, oldest to newest
13. 13

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in October 2019 and October 2024. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. 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.

    1924252626F623 across all 5 inspections, oldest to newest
14. 14

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in October 2019 and October 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.

    1924252626F656 across all 5 inspections, oldest to newest
15. 15

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in October 2025 and March 2026. 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.

    1924252626F677 across all 5 inspections, oldest to newest
16. 16

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in October 2019 and October 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1924252626F689 across all 5 inspections, oldest to newest
17. 17

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in October 2019 and October 2024. This citation covers oxygen, breathing treatments and other respiratory care. 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.

    1924252626F695 across all 5 inspections, oldest to newest
18. 18

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in October 2019 and March 2026. The agency describes it this way: Post nurse staffing information every day. 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.

    1924252626F732 across all 5 inspections, oldest to newest
19. 19

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in October 2019 and March 2026. 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.

    1924252626F757 across all 5 inspections, oldest to newest
20. 20

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in October 2024 and March 2026. This citation covers how food is stored, prepared and served. 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.

    1924252626F812 across all 5 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 five inspections, most seriously at level E.

2. 02

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

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

3. 03

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

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

4. 04

   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 D.

5. 05

   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.

6. 06

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

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

7. 07

   May we try a meal, and how do you check food temperature by the time it reaches residents?

   Food Quality and Temperature: cited in three inspections, most seriously at level D.

8. 08

   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.

9. 09

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

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

10. 10

    How do we file a grievance, who answers it, and how quickly?

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

11. 11

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.

12. 12

    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.

13. 13

    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 E.

14. 14

    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.

15. 15

    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.

16. 16

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

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

17. 17

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

18. 18

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in two inspections, most seriously at level D.

19. 19

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

    Citation F757: 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 D.

21. 21

    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 2026.

22. 22

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

    A $13,270 civil money penalty was imposed October 21, 2024. CMS publishes the fine, not whether it has been paid.

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 Oct 28, 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 Oct 21, 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 4, 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 Mar 3, 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 · 215181

  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.