The Vardell Report.Carmel Hills Wellness & Rehabilitation

Across 9 inspections from March 2020 to March 2026, state surveyors documented 79 findings at Carmel Hills Wellness & Rehabilitation; 78 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.

Inspections

9

2020–2026, complaint and standard

Findings

79

Deficiencies cited by state inspectors

Corrected

78

Of 79 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

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

1. Mar 312026

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for morePast Non-Compliance

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

2. May 212025

   Complaint investigation

   7 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jul 2, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 2, 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 Apr 22, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 2, 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 Jul 2, 2025
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jul 2, 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 Jul 2, 2025

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

3. Jan 162025

   Complaint investigation

   2 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 11, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Feb 11, 2025

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

4. Nov 252024

   Standard health inspection

   23 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jan 9, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jan 9, 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 ENo actual harm, potential for moreCorrected Jan 9, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Feb 11, 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 Feb 11, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • 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 Jan 9, 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 Jan 9, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 9, 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 Jan 9, 2025
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 9, 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 Jan 9, 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 Jan 9, 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 Jan 9, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 9, 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 Jan 9, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jan 9, 2025
   • 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 DNo actual harm, potential for moreCorrected Jan 9, 2025

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

5. Oct 162024

   Complaint investigation

   1 finding

   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level ENo actual harm, potential for moreCorrected Sep 11, 2024

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

6. Jun 282024

   Complaint investigation

   1 finding

   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jul 19, 2024

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

7. Feb 12024

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Feb 8, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 8, 2024

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

8. Mar 292023

   Standard health inspection

   28 findings

   • 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 13, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 13, 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 May 13, 2023
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected May 13, 2023
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected May 13, 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 May 13, 2023
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • 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 May 13, 2023
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • 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 May 13, 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 ENo actual harm, potential for moreCorrected May 13, 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 May 13, 2023
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected May 13, 2023
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • 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 13, 2023
   • 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 May 13, 2023
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected May 13, 2023
   • F926Have policies on smoking.Level DNo actual harm, potential for moreCorrected May 13, 2023

   Enforcement Action

   Civil money penalty, $20,787 imposed February 1, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 29, 2023, the nearest before the penalty date.

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

9. Mar 92020

   Standard health inspection

   14 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 23, 2020
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected Apr 23, 2020
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Apr 23, 2020
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected Apr 23, 2020
   • 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 Apr 23, 2020
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Apr 23, 2020
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Apr 23, 2020
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 23, 2020
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Apr 23, 2020
   • 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 23, 2020
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 23, 2020
   • 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 Apr 23, 2020
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Apr 23, 2020
   • 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 Apr 23, 2020

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

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

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

1. 1

   Food Quality and Temperature, Cited in Five Inspections

   Inspectors cited F804 in March 2020, March 2023, November 2024, January 2025 and May 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

   202324242424252526F804 across all 9 inspections, oldest to newest
2. 2

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in February 2024, November 2024 and January 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.

   202324242424252526F550 across all 9 inspections, oldest to newest
3. 3

   Continence and Catheter Care, Cited in Three Inspections

   Inspectors cited F690 in March 2020, March 2023 and November 2024. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

   202324242424252526F690 across all 9 inspections, oldest to newest
4. 4

   Citation F806, Cited in Three Inspections

   Inspectors cited F806 in March 2020, March 2023 and May 2025. The agency describes it this way: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. 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.

   202324242424252526F806 across all 9 inspections, oldest to newest
5. 5

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in March 2020, March 2023 and May 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.

   202324242424252526F812 across all 9 inspections, oldest to newest
6. 6

   Residents Taking Their Own Medication, Cited in Two Inspections

   Inspectors cited F554 in March 2023 and November 2024. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. 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.

   202324242424252526F554 across all 9 inspections, oldest to newest
7. 7

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in June 2024 and November 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202324242424252526F623 across all 9 inspections, oldest to newest
8. 8

   Accurate Assessments, Cited in Two Inspections

   Inspectors cited F641 in March 2020 and November 2024. 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.

   202324242424252526F641 across all 9 inspections, oldest to newest
9. 9

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in March 2020 and November 2024. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202324242424252526F656 across all 9 inspections, oldest to newest
10. 10

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in March 2023 and November 2024. 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.

    202324242424252526F657 across all 9 inspections, oldest to newest
11. 11

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in March 2023 and May 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

    202324242424252526F677 across all 9 inspections, oldest to newest
12. 12

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in March 2020 and November 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.

    202324242424252526F684 across all 9 inspections, oldest to newest
13. 13

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in March 2023 and November 2024. The agency describes it this way: Ensure 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. 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.

    202324242424252526F693 across all 9 inspections, oldest to newest
14. 14

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in March 2023 and November 2024. 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.

    202324242424252526F695 across all 9 inspections, oldest to newest
15. 15

    Dialysis Care, Cited in Two Inspections

    Inspectors cited F698 in March 2023 and November 2024. This citation covers care for residents who need dialysis. 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.

    202324242424252526F698 across all 9 inspections, oldest to newest
16. 16

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in March 2023 and November 2024. 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.

    202324242424252526F761 across all 9 inspections, oldest to newest
17. 17

    Keep all essential equipment working safely, Cited in Two Inspections

    Inspectors cited F908 in March 2020 and March 2023. 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.

    202324242424252526F908 across all 9 inspections, oldest to newest
18. 18

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in March 2023, February 2024, November 2024, May 2025 and March 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level J (immediate jeopardy). The March 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    202324242424252526F689 across all 9 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

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

   Food Quality and Temperature: cited in five inspections, most seriously at level E.

2. 02

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

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

3. 03

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in three inspections, most seriously at level D.

4. 04

   What changed after F806 was cited, and how do you check it now?

   Citation F806: cited in three inspections, most seriously at level E.

5. 05

   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 F.

6. 06

   How do you decide whether a resident may keep and take their own medications?

   Residents Taking Their Own Medication: cited in two inspections, most seriously at level E.

7. 07

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.

8. 08

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

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

9. 09

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

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

10. 10

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

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

11. 11

    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 E.

12. 12

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level G.

13. 13

    What changed after F693 was cited, and how do you check it now?

    Citation F693: cited in two inspections, most seriously at level D.

14. 14

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

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

15. 15

    How is dialysis care coordinated, and who monitors residents before and after treatment?

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

16. 16

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

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

17. 17

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

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

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 five inspections, most seriously at level J. The March 31, 2026 citation has no recorded correction date.

19. 19

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

    Insufficient nursing staff was cited in March 2023.

20. 20

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

    A $20,787 civil money penalty was imposed February 1, 2024. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Missouri state survey agency.

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

  Missouri state survey agency

  Inspection Mar 9, 2020 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Mar 29, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Feb 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Jun 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Nov 25, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Jan 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection May 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Mar 31, 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 · 265727

  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.