The Vardell Report.St Sophia Health & Rehabilitation Center

Across 19 inspections from May 2019 to May 2026, state surveyors documented 87 findings at St Sophia Health & Rehabilitation Center; 87 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

19

2019–2026, complaint and standard

Findings

87

Deficiencies cited by state inspectors

Corrected

87

Of 87 findings, with a recorded correction date

Penalties

4

3 fines; payment not published, 1 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 12026

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 1, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 1, 2026

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

2. Apr 12026

   Complaint investigation

   1 finding

   • 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 1, 2026

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

3. Mar 52026

   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 DNo actual harm, potential for moreCorrected Mar 28, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Mar 28, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 28, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 28, 2026

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

4. Feb 262026

   Complaint investigation

   2 findings

   • F567Honor the resident's right to manage his or her financial affairs.Level ENo actual harm, potential for moreCorrected Mar 13, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Feb 20, 2026

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

5. Jan 222026

   Complaint investigation

   3 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 Jan 23, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 23, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 23, 2026

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

6. Dec 312025

   Complaint investigation

   3 findings

   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jan 29, 2026
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Jan 29, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jan 29, 2026

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

7. Nov 62025

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level DNo actual harm, potential for moreCorrected Nov 17, 2025

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

8. Oct 302025

   Complaint investigation

   2 findings

   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Nov 18, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 18, 2025

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

9. Oct 32025

   Complaint investigation

   4 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Nov 7, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Nov 7, 2025
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level ENo actual harm, potential for moreCorrected Nov 7, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Nov 7, 2025

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

10. Aug 182025

    Complaint investigation

    4 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 Sep 24, 2025
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 24, 2025
    • 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 Sep 24, 2025
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 24, 2025

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

11. May 212025

    Complaint investigation

    2 findings

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 27, 2025
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Jun 17, 2025

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

12. Jan 282025

    Standard health inspection

    14 findings

    The same visit included a complaint investigation.

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Feb 27, 2025
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Feb 27, 2025
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Feb 27, 2025
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Feb 27, 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 Feb 27, 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 27, 2025
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 27, 2025

    Enforcement Action

    Civil money penalty, $33,560 imposed January 28, 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 January 28, 2025, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed January 28, 2025. Status: Closed, March 18, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 28, 2025, the nearest before the penalty date.

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

13. Nov 82024

    Complaint investigation

    3 findings

    • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
    • 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 Dec 12, 2024

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

14. Sep 272024

    Complaint investigation

    4 findings

    • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 28, 2024
    • 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 Dec 12, 2024

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

15. Jul 182024

    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 Jul 15, 2024

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

16. Jun 32024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 16, 2024

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

17. Oct 182023

    Complaint investigation

    3 findings

    • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Sep 29, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jun 13, 2023
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Nov 8, 2023

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

18. May 252023

    Standard health inspection

    14 findings

    • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level ENo actual harm, potential for moreCorrected Jul 6, 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 Jul 6, 2023
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level ENo actual harm, potential for moreCorrected Jul 6, 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 Jul 6, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jul 6, 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 Jul 6, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 6, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 6, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 6, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 6, 2023
    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jul 6, 2023
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jul 6, 2023
    • 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 6, 2023
    • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level DNo actual harm, potential for moreCorrected Jul 6, 2023

    Enforcement Action

    Civil money penalty, $21,590 imposed October 18, 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 May 25, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $14,053 imposed June 3, 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 May 25, 2023, the nearest before the penalty date.

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

19. May 172019

    Standard health inspection

    18 findings

    • F567Honor the resident's right to manage his or her financial affairs.Level FNo actual harm, potential for moreCorrected Jun 25, 2019
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Jun 25, 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 Jun 25, 2019
    • 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 Jun 25, 2019
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 25, 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 ENo actual harm, potential for moreCorrected Jun 25, 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 ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 25, 2019
    • 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 Jun 25, 2019
    • 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 Jun 25, 2019
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 25, 2019
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 25, 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 Seven Inspections

   Inspectors cited F689 in May 2019, May 2023, October 2023, July 2024, January 2025, August 2025 and November 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.

   19232324242424252525252525252626262626F689 across all 19 inspections, oldest to newest
2. 2

   Professional Standards, Cited in Six Inspections

   Inspectors cited F658 in May 2019, May 2023, January 2025, October 2025, January 2026 and March 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

   19232324242424252525252525252626262626F658 across all 19 inspections, oldest to newest
3. 3

   A Clean, Homelike Setting, Cited in Five Inspections

   Inspectors cited F584 in May 2023, January 2025, May 2025, August 2025 and December 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.

   19232324242424252525252525252626262626F584 across all 19 inspections, oldest to newest
4. 4

   Help With Daily Living, Cited in Five Inspections

   Inspectors cited F677 in May 2019, May 2023, January 2025, October 2025 and May 2026. 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.

   19232324242424252525252525252626262626F677 across all 19 inspections, oldest to newest
5. 5

   Citation F567, Cited in Four Inspections

   Inspectors cited F567 in May 2019, September 2024, November 2024 and February 2026. The agency describes it this way: Honor the resident's right to manage his or her financial affairs. 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.

   19232324242424252525252525252626262626F567 across all 19 inspections, oldest to newest
6. 6

   Citation F569, Cited in Four Inspections

   Inspectors cited F569 in May 2019, May 2023, September 2024 and November 2024. The agency describes it this way: Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. 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.

   19232324242424252525252525252626262626F569 across all 19 inspections, oldest to newest
7. 7

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in May 2019, May 2023, January 2025 and January 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.

   19232324242424252525252525252626262626F880 across all 19 inspections, oldest to newest
8. 8

   Quality of Care, Cited in Three Inspections

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

   19232324242424252525252525252626262626F684 across all 19 inspections, oldest to newest
9. 9

   Dignity and Resident Rights, Cited in Two Inspections

   Inspectors cited F550 in January 2025 and January 2026. 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.

   19232324242424252525252525252626262626F550 across all 19 inspections, oldest to newest
10. 10

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in January 2025 and February 2026. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232324242424252525252525252626262626F554 across all 19 inspections, oldest to newest
11. 11

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in January 2025 and May 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. 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.

    19232324242424252525252525252626262626F558 across all 19 inspections, oldest to newest
12. 12

    Citation F607, Cited in Two Inspections

    Inspectors cited F607 in October 2025 and March 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.

    19232324242424252525252525252626262626F607 across all 19 inspections, oldest to newest
13. 13

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in May 2023 and January 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.

    19232324242424252525252525252626262626F641 across all 19 inspections, oldest to newest
14. 14

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in May 2019 and August 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.

    19232324242424252525252525252626262626F656 across all 19 inspections, oldest to newest
15. 15

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in September 2024 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.

    19232324242424252525252525252626262626F693 across all 19 inspections, oldest to newest
16. 16

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in May 2019 and March 2026. 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.

    19232324242424252525252525252626262626F697 across all 19 inspections, oldest to newest
17. 17

    Dialysis Care, Cited in Two Inspections

    Inspectors cited F698 in May 2019 and August 2025. 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.

    19232324242424252525252525252626262626F698 across all 19 inspections, oldest to newest
18. 18

    Citation F745, Cited in Two Inspections

    Inspectors cited F745 in May 2023 and October 2025. The agency describes it this way: Provide medically-related social services to help each resident achieve the highest possible quality of life. 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.

    19232324242424252525252525252626262626F745 across all 19 inspections, oldest to newest
19. 19

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in May 2019 and December 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19232324242424252525252525252626262626F755 across all 19 inspections, oldest to newest
20. 20

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in May 2019 and January 2025. 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.

    19232324242424252525252525252626262626F761 across all 19 inspections, oldest to newest
21. 21

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in May 2019 and January 2025. 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.

    19232324242424252525252525252626262626F812 across all 19 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 seven inspections, most seriously at level J.

2. 02

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

   Professional Standards: cited in six inspections, most seriously at level E.

3. 03

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

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

4. 04

   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 five inspections, most seriously at level E.

5. 05

   What changed after F567 was cited, and how do you check it now?

   Citation F567: cited in four inspections, most seriously at level F.

6. 06

   What changed after F569 was cited, and how do you check it now?

   Citation F569: cited in four inspections, most seriously at level E.

7. 07

   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.

8. 08

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

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

9. 09

   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.

10. 10

    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 D.

11. 11

    How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

    Needs and Preferences: cited in two inspections, most seriously at level D.

12. 12

    What changed after F607 was cited, and how do you check it now?

    Citation F607: cited in two inspections, most seriously at level D.

13. 13

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

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

14. 14

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

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

15. 15

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

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

16. 16

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

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

17. 17

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

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

18. 18

    What changed after F745 was cited, and how do you check it now?

    Citation F745: cited in two inspections, most seriously at level D.

19. 19

    How often does the consultant pharmacist review each resident’s medications?

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

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 E.

21. 21

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

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

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 2025 fine, and has it been paid?

    A $33,560 civil money penalty was imposed January 28, 2025. CMS publishes the fine, not whether it has been paid. The record holds four 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 May 17, 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 May 25, 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 Oct 18, 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 Jun 3, 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 Jul 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)

  Missouri state survey agency

  Inspection Sep 27, 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 8, 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 28, 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 Aug 18, 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 Oct 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 Oct 30, 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 Nov 6, 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 Dec 31, 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 Jan 22, 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 Feb 26, 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 Mar 5, 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 1, 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 1, 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 · 265120

  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.