The Vardell Report.Pines Nursing and Rehab

Across 7 inspections from October 2018 to August 2026, state surveyors documented 183 findings at Pines Nursing and Rehab; 180 have a recorded correction and 3 await one; CMS lists 3 enforcement actions in the window.

Inspections

7

2018–2026, complaint and standard

Findings

183

Deficiencies cited by state inspectors

Corrected

180

Of 183 findings, with a recorded correction date

Penalties

3

3 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. Aug 192026

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level ENo actual harm, potential for morePast Non-Compliance

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

2. Jul 22026

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 17, 2026

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

3. Mar 122026

   Complaint investigation

   12 findings

   • 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 28, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Apr 28, 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 ENo actual harm, potential for moreCorrected Apr 28, 2026
   • 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 Apr 28, 2026
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Apr 28, 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 Apr 28, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 28, 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 28, 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 28, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 28, 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 28, 2026
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Apr 28, 2026

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

4. Sep 42025

   Standard health inspection

   38 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 Nov 10, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 10, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Nov 10, 2025
   • 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 Nov 10, 2025
   • 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 Nov 10, 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 ENo actual harm, potential for moreCorrected Nov 10, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Nov 10, 2025
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Nov 10, 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 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 ENo actual harm, potential for moreCorrected Nov 10, 2025
   • 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 Nov 10, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Nov 10, 2025
   • 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 Nov 10, 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 10, 2025
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F572Give residents a notice of rights, rules, services and charges.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Nov 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 Nov 10, 2025
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 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 Nov 10, 2025
   • 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 10, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • 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 10, 2025
   • 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 Nov 10, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Nov 10, 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 Nov 10, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Nov 10, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Nov 10, 2025

   Enforcement Action

   Civil money penalty, $19,635 imposed July 2, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 4, 2025, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $27,378 imposed July 2, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 4, 2025, the nearest before the penalty date.

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

5. Mar 192025

   Complaint investigation

   37 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 27, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected May 27, 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 FNo actual harm, potential for moreCorrected Jun 20, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected May 27, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected May 27, 2025
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected May 27, 2025
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Jun 20, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Jun 20, 2025
   • 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 Jun 20, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected May 27, 2025
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected May 27, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected May 27, 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 Jun 20, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • 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 Jun 20, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jun 20, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 20, 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 May 27, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jun 20, 2025
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • 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 Jun 16, 2025
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected May 27, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected May 27, 2025

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

6. Sep 282022

   Standard health inspection

   64 findings

   • 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 Mar 18, 2023
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Nov 27, 2022
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • 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 FNo actual harm, potential for moreCorrected Mar 18, 2023
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 Nov 27, 2022
   • 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 Mar 3, 2023
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Level FNo actual harm, potential for moreCorrected Mar 3, 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 FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 Mar 3, 2023
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • F886Perform COVID19 testing on residents and staff.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Nov 27, 2022
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 Nov 27, 2022
   • 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 Nov 27, 2022
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Mar 18, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 Mar 3, 2023
   • 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 Mar 3, 2023
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Mar 18, 2023
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 Mar 18, 2023
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • 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 27, 2022
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Mar 3, 2023
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Nov 27, 2022
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • 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 Mar 3, 2023
   • 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 27, 2022
   • 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 Mar 3, 2023
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F775Keep complete, dated laboratory records in the resident's record.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Nov 27, 2022
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Mar 3, 2023
   • 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 Mar 3, 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 CPotential for minimal harmCorrected Nov 27, 2022
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Nov 27, 2022

   Enforcement Action

   Civil money penalty, $24,088 imposed March 19, 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 September 28, 2022, the nearest before the penalty date.

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

7. Oct 252018

   Standard health inspection

   28 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • 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 1, 2018
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • 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 Dec 1, 2018
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Dec 1, 2018
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • 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 Dec 1, 2018
   • 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 Dec 1, 2018
   • 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 Dec 1, 2018
   • 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 May 10, 2018
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • 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 Dec 1, 2018
   • 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 Dec 1, 2018
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 1, 2018
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Dec 1, 2018

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

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

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

1. 1

   Telling Families About Changes, Cited in Five Inspections

   Inspectors cited F580 in October 2018, September 2022, March 2025, September 2025 and March 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   18222525262626F580 across all 7 inspections, oldest to newest
2. 2

   A Clean, Homelike Setting, Cited in Five Inspections

   Inspectors cited F584 in October 2018, September 2022, March 2025, September 2025 and March 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   18222525262626F584 across all 7 inspections, oldest to newest
3. 3

   Care Plan Timing and Review, Cited in Five Inspections

   Inspectors cited F657 in October 2018, September 2022, March 2025, September 2025 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   18222525262626F657 across all 7 inspections, oldest to newest
4. 4

   Medical Records, Cited in Five Inspections

   Inspectors cited F842 in October 2018, September 2022, March 2025, September 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.

   18222525262626F842 across all 7 inspections, oldest to newest
5. 5

   Keep all essential equipment working safely, Cited in Five Inspections

   Inspectors cited F908 in October 2018, September 2022, March 2025, September 2025 and March 2026. The agency describes it this way: Keep all essential equipment working safely. 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.

   18222525262626F908 across all 7 inspections, oldest to newest
6. 6

   Dignity and Resident Rights, Cited in Four Inspections

   Inspectors cited F550 in September 2022, March 2025, September 2025 and March 2026. 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.

   18222525262626F550 across all 7 inspections, oldest to newest
7. 7

   Accurate Assessments, Cited in Four Inspections

   Inspectors cited F641 in October 2018, March 2025, September 2025 and March 2026. 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.

   18222525262626F641 across all 7 inspections, oldest to newest
8. 8

   Care Plans, Cited in Four Inspections

   Inspectors cited F656 in October 2018, September 2022, September 2025 and March 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 F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   18222525262626F656 across all 7 inspections, oldest to newest
9. 9

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in October 2018, September 2022, March 2025 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

   18222525262626F686 across all 7 inspections, oldest to newest
10. 10

    Accident Hazards and Supervision, Cited in Four Inspections

    Inspectors cited F689 in September 2022, March 2025, September 2025 and July 2026. 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.

    18222525262626F689 across all 7 inspections, oldest to newest
11. 11

    Kitchen and Food Safety, Cited in Four Inspections

    Inspectors cited F812 in October 2018, September 2022, March 2025 and September 2025. 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.

    18222525262626F812 across all 7 inspections, oldest to newest
12. 12

    Citation F919, Cited in Four Inspections

    Inspectors cited F919 in October 2018, September 2022, March 2025 and September 2025. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. 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.

    18222525262626F919 across all 7 inspections, oldest to newest
13. 13

    Citation F565, Cited in Three Inspections

    Inspectors cited F565 in October 2018, September 2022 and September 2025. The agency describes it this way: Honor the resident's right to organize and participate in resident/family groups in the facility. 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.

    18222525262626F565 across all 7 inspections, oldest to newest
14. 14

    Treatment Choices and Advance Directives, Cited in Three Inspections

    Inspectors cited F578 in October 2018, September 2022 and September 2025. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. 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.

    18222525262626F578 across all 7 inspections, oldest to newest
15. 15

    Nutrition and Hydration, Cited in Three Inspections

    Inspectors cited F692 in October 2018, September 2022 and March 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.

    18222525262626F692 across all 7 inspections, oldest to newest
16. 16

    Respiratory Care, Cited in Three Inspections

    Inspectors cited F695 in September 2022, September 2025 and March 2026. This citation covers oxygen, breathing treatments and other respiratory care. 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.

    18222525262626F695 across all 7 inspections, oldest to newest
17. 17

    Nursing Staff Levels, Cited in Three Inspections

    Inspectors cited F725 in October 2018, September 2022 and March 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F725 across all 7 inspections, oldest to newest
18. 18

    Post nurse staffing information every day, Cited in Three Inspections

    Inspectors cited F732 in September 2022, March 2025 and September 2025. 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.

    18222525262626F732 across all 7 inspections, oldest to newest
19. 19

    Citation F756, Cited in Three Inspections

    Inspectors cited F756 in October 2018, September 2022 and September 2025. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F756 across all 7 inspections, oldest to newest
20. 20

    Citation F757, Cited in Three Inspections

    Inspectors cited F757 in October 2018, September 2022 and March 2025. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F757 across all 7 inspections, oldest to newest
21. 21

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in September 2022, March 2025 and September 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. 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.

    18222525262626F761 across all 7 inspections, oldest to newest
22. 22

    Citation F809, Cited in Three Inspections

    Inspectors cited F809 in October 2018, September 2022 and March 2025. The agency describes it this way: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F809 across all 7 inspections, oldest to newest
23. 23

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in October 2018, September 2022 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F880 across all 7 inspections, oldest to newest
24. 24

    Citation F921, Cited in Three Inspections

    Inspectors cited F921 in September 2022, September 2025 and March 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F921 across all 7 inspections, oldest to newest
25. 25

    Citation F925, Cited in Three Inspections

    Inspectors cited F925 in March 2025, September 2025 and March 2026. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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.

    18222525262626F925 across all 7 inspections, oldest to newest
26. 26

    Citation F947, Cited in Three Inspections

    Inspectors cited F947 in September 2022, March 2025 and September 2025. The agency describes it this way: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. 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.

    18222525262626F947 across all 7 inspections, oldest to newest
27. 27

    Citation F561, Cited in Two Inspections

    Inspectors cited F561 in October 2018 and September 2025. 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.

    18222525262626F561 across all 7 inspections, oldest to newest
28. 28

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in October 2018 and March 2025. 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.

    18222525262626F600 across all 7 inspections, oldest to newest
29. 29

    Citation F602, Cited in Two Inspections

    Inspectors cited F602 in September 2022 and March 2025. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. 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.

    18222525262626F602 across all 7 inspections, oldest to newest
30. 30

    Reporting Suspected Abuse, Cited in Two Inspections

    Inspectors cited F609 in March 2025 and September 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.

    18222525262626F609 across all 7 inspections, oldest to newest
31. 31

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in March 2025 and September 2025. 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.

    18222525262626F610 across all 7 inspections, oldest to newest
32. 32

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in October 2018 and September 2022. 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.

    18222525262626F623 across all 7 inspections, oldest to newest
33. 33

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in October 2018 and September 2022. 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.

    18222525262626F625 across all 7 inspections, oldest to newest
34. 34

    Citation F636, Cited in Two Inspections

    Inspectors cited F636 in September 2022 and September 2025. The agency describes it this way: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. 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.

    18222525262626F636 across all 7 inspections, oldest to newest
35. 35

    Citation F638, Cited in Two Inspections

    Inspectors cited F638 in September 2022 and March 2025. The agency describes it this way: Assure that each resident’s assessment is updated at least once every 3 months. 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.

    18222525262626F638 across all 7 inspections, oldest to newest
36. 36

    The First 48 Hours, Cited in Two Inspections

    Inspectors cited F655 in October 2018 and September 2022. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

    18222525262626F655 across all 7 inspections, oldest to newest
37. 37

    Mobility and Range of Motion, Cited in Two Inspections

    Inspectors cited F688 in September 2022 and March 2025. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F688 across all 7 inspections, oldest to newest
38. 38

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in October 2018 and September 2022. 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.

    18222525262626F697 across all 7 inspections, oldest to newest
39. 39

    Citation F730, Cited in Two Inspections

    Inspectors cited F730 in September 2022 and March 2025. The agency describes it this way: Observe each nurse aide's job performance and give regular training. 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.

    18222525262626F730 across all 7 inspections, oldest to newest
40. 40

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in October 2018 and March 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    18222525262626F758 across all 7 inspections, oldest to newest
41. 41

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in September 2022 and March 2025. This citation covers whether residents are free from significant medication errors. 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.

    18222525262626F760 across all 7 inspections, oldest to newest
42. 42

    Citation F790, Cited in Two Inspections

    Inspectors cited F790 in September 2022 and September 2025. The agency describes it this way: Provide routine and 24-hour emergency dental care for each resident. 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.

    18222525262626F790 across all 7 inspections, oldest to newest
43. 43

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in September 2022 and March 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

    18222525262626F804 across all 7 inspections, oldest to newest
44. 44

    Citation F850, Cited in Two Inspections

    Inspectors cited F850 in September 2022 and March 2025. The agency describes it this way: Hire a qualified full-time social worker in a facility with more than 120 beds. 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.

    18222525262626F850 across all 7 inspections, oldest to newest
45. 45

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in September 2022 and September 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

    18222525262626F883 across all 7 inspections, oldest to newest
46. 46

    Grievances, No Recorded Correction

    F585 was cited in September 2025 and August 2026. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    18222525262626F585 across all 7 inspections, oldest to newest
47. 47

    Quality of Care, No Recorded Correction

    F684 was cited in October 2018, September 2022, March 2025, September 2025 and August 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious was level G (actual harm). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    18222525262626F684 across all 7 inspections, oldest to newest
48. 48

    Citation F940, No Recorded Correction

    F940 was cited in August 2026. The agency describes it this way: Develop, implement, and/or maintain an effective training program for all new and existing staff members. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    18222525262626F940 across all 7 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 quickly will we hear about a fall, an injury or a change in condition, and from whom?

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

2. 02

   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 F.

3. 03

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in five inspections, most seriously at level E.

4. 04

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

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

5. 05

   What changed after F908 was cited, and how do you check it now?

   Keep all essential equipment working safely: cited in five inspections, most seriously at level F.

6. 06

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

   Dignity and Resident Rights: cited in four inspections, most seriously at level E.

7. 07

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

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

8. 08

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

   Care Plans: cited in four inspections, most seriously at level F.

9. 09

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

   Pressure Injury Care: cited in four inspections, most seriously at level E.

10. 10

    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 J.

11. 11

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

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

12. 12

    What changed after F919 was cited, and how do you check it now?

    Citation F919: cited in four inspections, most seriously at level E.

13. 13

    What changed after F565 was cited, and how do you check it now?

    Citation F565: cited in three inspections, most seriously at level F.

14. 14

    How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

    Treatment Choices and Advance Directives: cited in three inspections, most seriously at level E.

15. 15

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

    Nutrition and Hydration: cited in three inspections, most seriously at level G.

16. 16

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

    Respiratory Care: cited in three inspections, most seriously at level E.

17. 17

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

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

18. 18

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

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

19. 19

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

    Citation F756: cited in three inspections, most seriously at level E.

20. 20

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

    Citation F757: cited in three inspections, most seriously at level E.

21. 21

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

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

22. 22

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

    Citation F809: cited in three inspections, most seriously at level E.

23. 23

    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.

24. 24

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

    Citation F921: cited in three inspections, most seriously at level E.

25. 25

    What changed after F925 was cited, and how do you check it now?

    Citation F925: cited in three inspections, most seriously at level F.

26. 26

    What changed after F947 was cited, and how do you check it now?

    Citation F947: cited in three inspections, most seriously at level F.

27. 27

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

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

28. 28

    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.

29. 29

    What changed after F602 was cited, and how do you check it now?

    Citation F602: cited in two inspections, most seriously at level D.

30. 30

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

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

31. 31

    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.

32. 32

    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.

33. 33

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

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

34. 34

    What changed after F636 was cited, and how do you check it now?

    Citation F636: cited in two inspections, most seriously at level E.

35. 35

    What changed after F638 was cited, and how do you check it now?

    Citation F638: cited in two inspections, most seriously at level D.

36. 36

    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 E.

37. 37

    What do you do to keep residents moving, and who provides range-of-motion care?

    Mobility and Range of Motion: cited in two inspections, most seriously at level D.

38. 38

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

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

39. 39

    What changed after F730 was cited, and how do you check it now?

    Citation F730: cited in two inspections, most seriously at level F.

40. 40

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

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

41. 41

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

    Significant Medication Errors: cited in two inspections, most seriously at level E.

42. 42

    What changed after F790 was cited, and how do you check it now?

    Citation F790: cited in two inspections, most seriously at level D.

43. 43

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

    Food Quality and Temperature: cited in two inspections, most seriously at level F.

44. 44

    What changed after F850 was cited, and how do you check it now?

    Citation F850: cited in two inspections, most seriously at level F.

45. 45

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level E.

46. 46

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

    Grievances: cited in two inspections, most seriously at level E. The August 19, 2026 citation has no recorded correction date.

47. 47

    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 five inspections, most seriously at level G. The August 19, 2026 citation has no recorded correction date.

48. 48

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

    Citation F940: cited in one inspections, most seriously at level E. The August 19, 2026 citation has no recorded correction date.

49. 49

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

    A $19,635 civil money penalty was imposed July 2, 2026. 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 Oct 25, 2018 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Sep 28, 2022 · 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 19, 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 Sep 4, 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 Mar 12, 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 2, 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 Aug 19, 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 · 215010

  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.