The Vardell Report.White Oak Rehabilitation and Nursing Center

Across 5 inspections from May 2021 to June 2026, state surveyors documented 97 findings at White Oak Rehabilitation and Nursing Center; 97 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

5

2021–2026, standard and complaint

Findings

97

Deficiencies cited by state inspectors

Corrected

97

Of 97 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. Jun 222026

   Standard health inspection

   24 findings

   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 22, 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 ENo actual harm, potential for moreCorrected Jul 22, 2026
   • 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 Jul 22, 2026
   • 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 Jul 22, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 22, 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 Jul 22, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Jul 22, 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 Jul 22, 2026
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jul 22, 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 Jul 22, 2026
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jul 22, 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 Jul 22, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Jul 22, 2026
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Jul 22, 2026

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

2. Apr 32026

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 24, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 24, 2026

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

3. Apr 292025

   Standard health inspection

   21 findings

   The same visit included a complaint investigation.

   • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level JImmediate jeopardyCorrected Jul 8, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jul 8, 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 Jul 8, 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 Jul 8, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 8, 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 Jul 8, 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 Jul 8, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 8, 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 Jul 8, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 8, 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 Jul 8, 2025
   • F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Jul 8, 2025

   Enforcement Action

   Civil money penalty, $76,515 imposed April 29, 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 April 29, 2025, the nearest before the penalty date.

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

4. Jan 182024

   Complaint investigation

   14 findings

   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
   • 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 Feb 29, 2024
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 29, 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 Feb 29, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Feb 29, 2024

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

5. May 282021

   Standard health inspection

   36 findings

   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Jul 26, 2021
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 Jul 26, 2021
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 Jul 26, 2021
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 ENo actual harm, potential for moreCorrected Jul 26, 2021
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 26, 2021
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 Jul 26, 2021
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 Jul 26, 2021
   • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • 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 Jul 26, 2021
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Jul 26, 2021
   • F924Put firmly secured handrails on each side of hallways.Level DNo actual harm, potential for moreCorrected Jul 26, 2021

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

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

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

1. 1

   Care Plan Timing and Review, Cited in Four Inspections

   Inspectors cited F657 in May 2021, January 2024, April 2025 and June 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.

   2124252626F657 across all 5 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in May 2021, January 2024, April 2025 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2124252626F684 across all 5 inspections, oldest to newest
3. 3

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in May 2021, January 2024, April 2025 and June 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.

   2124252626F842 across all 5 inspections, oldest to newest
4. 4

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in May 2021, April 2025, April 2026 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.

   2124252626F880 across all 5 inspections, oldest to newest
5. 5

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in May 2021, April 2025 and June 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.

   2124252626F584 across all 5 inspections, oldest to newest
6. 6

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in May 2021, January 2024 and April 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2124252626F609 across all 5 inspections, oldest to newest
7. 7

   Accurate Assessments, Cited in Three Inspections

   Inspectors cited F641 in May 2021, April 2025 and June 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.

   2124252626F641 across all 5 inspections, oldest to newest
8. 8

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in May 2021, January 2024 and April 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.

   2124252626F656 across all 5 inspections, oldest to newest
9. 9

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in May 2021, January 2024 and June 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2124252626F761 across all 5 inspections, oldest to newest
10. 10

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in May 2021, April 2025 and June 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2124252626F812 across all 5 inspections, oldest to newest
11. 11

    Keep all essential equipment working safely, Cited in Three Inspections

    Inspectors cited F908 in May 2021, January 2024 and June 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.

    2124252626F908 across all 5 inspections, oldest to newest
12. 12

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in May 2021 and April 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2124252626F550 across all 5 inspections, oldest to newest
13. 13

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in May 2021 and January 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2124252626F610 across all 5 inspections, oldest to newest
14. 14

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in May 2021 and January 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.

    2124252626F623 across all 5 inspections, oldest to newest
15. 15

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in January 2024 and April 2025. 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.

    2124252626F625 across all 5 inspections, oldest to newest
16. 16

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in April 2025 and June 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

    2124252626F658 across all 5 inspections, oldest to newest
17. 17

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in January 2024 and June 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.

    2124252626F677 across all 5 inspections, oldest to newest
18. 18

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in May 2021 and April 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2124252626F689 across all 5 inspections, oldest to newest
19. 19

    Citation F730, Cited in Two Inspections

    Inspectors cited F730 in May 2021 and June 2026. The agency describes it this way: Observe each nurse aide's job performance and give regular training. 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.

    2124252626F730 across all 5 inspections, oldest to newest
20. 20

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in May 2021 and April 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.

    2124252626F732 across all 5 inspections, oldest to newest
21. 21

    Citation F868, Cited in Two Inspections

    Inspectors cited F868 in May 2021 and June 2026. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2124252626F868 across all 5 inspections, oldest to newest
22. 22

    Citation F919, Cited in Two Inspections

    Inspectors cited F919 in January 2024 and June 2026. 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.

    2124252626F919 across all 5 inspections, oldest to newest
23. 23

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in April 2025 and June 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.

    2124252626F921 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

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

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

2. 02

   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 four inspections, most seriously at level D.

3. 03

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

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

4. 04

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in four inspections, most seriously at level E.

5. 05

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

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

6. 06

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

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

7. 07

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

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

8. 08

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

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

9. 09

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

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

10. 10

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

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

11. 11

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

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

12. 12

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

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

13. 13

    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.

14. 14

    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.

15. 15

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

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

16. 16

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

    Professional Standards: cited in two inspections, most seriously at level D.

17. 17

    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.

18. 18

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

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

19. 19

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

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

20. 20

    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.

21. 21

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

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

22. 22

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

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

23. 23

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

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

24. 24

    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 May 2021.

25. 25

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

    A $76,515 civil money penalty was imposed April 29, 2025. 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 May 28, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Jan 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Maryland state survey agency

  Inspection Apr 29, 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 Apr 3, 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 Jun 22, 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 · 215024

  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.