The Vardell Report.Heritage Care Center

Across 18 inspections from July 2019 to May 2026, state surveyors documented 94 findings at Heritage Care Center; 94 have a recorded correction; CMS lists 7 enforcement actions in the window.

Inspections

18

2019–2026, complaint and standard

Findings

94

Deficiencies cited by state inspectors

Corrected

94

Of 94 findings, with a recorded correction date

Penalties

7

5 fines; payment not published, 2 closed

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. May 152026

   Complaint investigation

   1 finding

   • F586Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.Level DNo actual harm, potential for moreCorrected May 22, 2026

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

2. Apr 162026

   Complaint investigation

   1 finding

   • F555Honor the resident's right to choose his or her attending physician.Level ENo actual harm, potential for moreCorrected Apr 29, 2026

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

3. Feb 172026

   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 18, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 18, 2026

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

4. Sep 92025

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • 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 Oct 15, 2025
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Oct 15, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 15, 2025
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 15, 2025
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Oct 15, 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 Oct 15, 2025
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected Oct 15, 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 ENo actual harm, potential for moreCorrected Oct 15, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Oct 15, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Oct 15, 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 Oct 15, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 15, 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 Oct 15, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 15, 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 Oct 15, 2025

   Enforcement Action

   Civil money penalty, $52,930 imposed February 17, 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 9, 2025, the nearest before the penalty date.

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

5. Jun 262025

   Complaint investigation

   2 findings

   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Jul 25, 2025
   • F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Level DNo actual harm, potential for moreCorrected Jul 25, 2025

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

6. May 232025

   Complaint investigation

   1 finding

   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 10, 2025

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

7. Apr 252025

   Complaint investigation

   5 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 24, 2025
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level GActual harmCorrected May 24, 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 May 24, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 24, 2025
   • 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 May 24, 2025

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

8. Mar 142025

   Complaint investigation

   9 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 24, 2025
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level GActual harmCorrected May 24, 2025
   • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level GActual harmCorrected May 24, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Jul 25, 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 Apr 14, 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 May 24, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 24, 2025
   • 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 May 24, 2025
   • F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Level DNo actual harm, potential for moreCorrected Jul 25, 2025

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

9. Feb 32025

   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 16, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 16, 2025

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

10. Dec 262024

    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 16, 2025
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 16, 2025

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

11. Sep 122024

    Complaint investigation

    1 finding

    • 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 Oct 21, 2024

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

12. Aug 52024

    Complaint investigation

    3 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 9, 2024
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Aug 9, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 9, 2024

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

13. Jun 142024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jun 11, 2024

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

14. May 22024

    Complaint investigation

    1 finding

    • 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 Apr 22, 2024

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

15. Jan 302024

    Complaint investigation

    4 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Mar 13, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Mar 13, 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 Mar 13, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 13, 2024

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

16. Dec 122023

    Complaint investigation

    7 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Mar 13, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 16, 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 JImmediate jeopardyCorrected Mar 13, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Mar 13, 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 Mar 13, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
    • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Dec 7, 2023

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

17. Sep 292023

    Standard health inspection

    20 findings

    • F880Provide and implement an infection prevention and control program.Level JImmediate jeopardyCorrected Nov 13, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Nov 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 Nov 13, 2023
    • F567Honor the resident's right to manage his or her financial affairs.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
    • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
    • F570Assure the security of all personal funds of residents deposited with the facility.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 13, 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 DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 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 Nov 13, 2023
    • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Nov 13, 2023
    • 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 Nov 13, 2023

    Enforcement Action

    Civil money penalty, $45,311 imposed December 12, 2023. 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 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed December 12, 2023. Status: Closed, March 13, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $16,801 imposed June 14, 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 September 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $108,179 imposed December 26, 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 September 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $146,162 imposed March 14, 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 29, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 14, 2025. Status: Closed, July 25, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 29, 2023, the nearest before the penalty date.

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

18. Jul 262019

    Standard health inspection

    12 findings

    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 8, 2019
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Sep 8, 2019
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 8, 2019
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 8, 2019
    • F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Level DNo actual harm, potential for moreCorrected Sep 8, 2019
    • 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 Sep 8, 2019
    • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Sep 8, 2019
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 8, 2019
    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Sep 8, 2019
    • 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 Sep 8, 2019
    • 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 Sep 8, 2019
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 9, 2019

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

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

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

1. 1

   Accident Hazards and Supervision, Cited in Nine Inspections

   Inspectors cited F689 in September 2023, December 2023, June 2024, December 2024, February 2025, March 2025, April 2025, September 2025 and February 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.

   192323242424242424252525252525262626F689 across all 18 inspections, oldest to newest
2. 2

   Investigating Alleged Violations, Cited in Six Inspections

   Inspectors cited F610 in September 2023, December 2023, January 2024, December 2024, February 2025 and February 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192323242424242424252525252525262626F610 across all 18 inspections, oldest to newest
3. 3

   Protection From Abuse and Neglect, Cited in Five Inspections

   Inspectors cited F600 in December 2023, January 2024, May 2024, September 2024 and September 2025. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

   192323242424242424252525252525262626F600 across all 18 inspections, oldest to newest
4. 4

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in July 2019, September 2023, August 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.

   192323242424242424252525252525262626F880 across all 18 inspections, oldest to newest
5. 5

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in December 2023, January 2024 and September 2025. 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.

   192323242424242424252525252525262626F584 across all 18 inspections, oldest to newest
6. 6

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in September 2023, December 2023 and January 2024. 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.

   192323242424242424252525252525262626F609 across all 18 inspections, oldest to newest
7. 7

   Notice Before Transfer or Discharge, Cited in Three Inspections

   Inspectors cited F623 in September 2023, March 2025 and April 2025. 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.

   192323242424242424252525252525262626F623 across all 18 inspections, oldest to newest
8. 8

   Citation F553, Cited in Two Inspections

   Inspectors cited F553 in March 2025 and April 2025. The agency describes it this way: Allow resident to participate in the development and implementation of his or her person-centered plan of care. 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.

   192323242424242424252525252525262626F553 across all 18 inspections, oldest to newest
9. 9

   Citation F568, Cited in Two Inspections

   Inspectors cited F568 in September 2023 and September 2025. The agency describes it this way: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. 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.

   192323242424242424252525252525262626F568 across all 18 inspections, oldest to newest
10. 10

    Citation F576, Cited in Two Inspections

    Inspectors cited F576 in March 2025 and June 2025. The agency describes it this way: Ensure residents have reasonable access to and privacy in their use of communication methods. 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.

    192323242424242424252525252525262626F576 across all 18 inspections, oldest to newest
11. 11

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in July 2019 and September 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192323242424242424252525252525262626F641 across all 18 inspections, oldest to newest
12. 12

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in July 2019 and September 2023. 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.

    192323242424242424252525252525262626F656 across all 18 inspections, oldest to newest
13. 13

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in March 2025 and April 2025. 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.

    192323242424242424252525252525262626F658 across all 18 inspections, oldest to newest
14. 14

    Citation F661, Cited in Two Inspections

    Inspectors cited F661 in March 2025 and April 2025. The agency describes it this way: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. 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.

    192323242424242424252525252525262626F661 across all 18 inspections, oldest to newest
15. 15

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in May 2025 and September 2025. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192323242424242424252525252525262626F697 across all 18 inspections, oldest to newest
16. 16

    Citation F741, Cited in Two Inspections

    Inspectors cited F741 in March 2025 and June 2025. The agency describes it this way: Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. 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.

    192323242424242424252525252525262626F741 across all 18 inspections, oldest to newest
17. 17

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in July 2019 and September 2023. 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.

    192323242424242424252525252525262626F758 across all 18 inspections, oldest to newest
18. 18

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in September 2023 and August 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.

    192323242424242424252525252525262626F759 across all 18 inspections, oldest to newest
19. 19

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in August 2024 and September 2025. This citation covers whether residents are free from significant medication errors. 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.

    192323242424242424252525252525262626F760 across all 18 inspections, oldest to newest
20. 20

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in July 2019 and September 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192323242424242424252525252525262626F761 across all 18 inspections, oldest to newest
21. 21

    Citation F925, Cited in Two Inspections

    Inspectors cited F925 in July 2019 and March 2025. 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.

    192323242424242424252525252525262626F925 across all 18 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What 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 nine inspections, most seriously at level J.

2. 02

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in six inspections, most seriously at level D.

3. 03

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

   Protection From Abuse and Neglect: cited in five inspections, most seriously at level J.

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 J.

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

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

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

8. 08

   What changed after F553 was cited, and how do you check it now?

   Citation F553: cited in two inspections, most seriously at level G.

9. 09

   What changed after F568 was cited, and how do you check it now?

   Citation F568: cited in two inspections, most seriously at level E.

10. 10

    What changed after F576 was cited, and how do you check it now?

    Citation F576: cited in two inspections, most seriously at level E.

11. 11

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

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

12. 12

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

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

13. 13

    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.

14. 14

    What changed after F661 was cited, and how do you check it now?

    Citation F661: cited in two inspections, most seriously at level D.

15. 15

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

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

16. 16

    What changed after F741 was cited, and how do you check it now?

    Citation F741: cited in two inspections, most seriously at level D.

17. 17

    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.

18. 18

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level E.

19. 19

    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 D.

20. 20

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

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

21. 21

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

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

22. 22

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

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

23. 23

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

    A $52,930 civil money penalty was imposed February 17, 2026. CMS publishes the fine, not whether it has been paid. The record holds seven enforcement actions in the window.

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 Jul 26, 2019 · 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 Sep 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 Dec 12, 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 Jan 30, 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 May 2, 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 14, 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 Aug 5, 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 Sep 12, 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 Dec 26, 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 Feb 3, 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 14, 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 Apr 25, 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 23, 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 Jun 26, 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 Sep 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Feb 17, 2026 · 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 Apr 16, 2026 · 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 15, 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 · 265534

  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.