The Vardell Report.Grande Oaks

Across 12 inspections from September 2022 to April 2026, state surveyors documented 88 findings at Grande Oaks; 88 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

12

2022–2026, standard and complaint

Findings

88

Deficiencies cited by state inspectors

Corrected

88

Of 88 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. Apr 292026

   Standard health inspection

   25 findings

   The same visit included a complaint investigation.

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jun 12, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jun 12, 2026
   • 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 Jun 12, 2026
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Jun 12, 2026
   • 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 Jun 12, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 22, 2026
   • 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 Jun 12, 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 Jun 12, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 12, 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 12, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • 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 12, 2026
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • 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 Jun 12, 2026
   • 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 DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • 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 DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel CPotential for minimal harmCorrected Jun 12, 2026

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

2. Oct 282025

   Complaint investigation

   7 findings

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 31, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Oct 31, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Oct 31, 2025

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

3. Mar 272025

   Standard health inspection

   2 findings

   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Apr 15, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 15, 2025

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

4. Dec 22024

   Complaint investigation

   16 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 18, 2024
   • 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 FNo actual harm, potential for moreCorrected Jan 3, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Jan 3, 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 FNo actual harm, potential for moreCorrected Jan 3, 2025
   • 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 Jan 3, 2025
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level FNo actual harm, potential for moreCorrected Jan 3, 2025
   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Jan 3, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Jan 3, 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 3, 2025
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Jan 3, 2025
   • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Jan 3, 2025

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

5. Sep 182024

   Complaint investigation

   6 findings

   The same visit included an infection control inspection.

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 8, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 8, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 8, 2024
   • 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 8, 2024
   • 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 Oct 8, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 8, 2024

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

6. Sep 112024

   Complaint investigation

   1 finding

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 8, 2024

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

7. Jul 112024

   Complaint investigation

   3 findings

   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Aug 2, 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 Aug 2, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 2, 2024

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

8. May 202024

   Complaint investigation

   3 findings

   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level FNo actual harm, potential for moreCorrected Jun 7, 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 Jun 7, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jun 7, 2024

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

9. Mar 212024

   Complaint investigation

   2 findings

   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 19, 2024
   • 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 Apr 19, 2024

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

10. Feb 72024

    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 moreCorrected Apr 19, 2024

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

11. Dec 182023

    Complaint investigation

    1 finding

    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jan 26, 2024

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

12. Sep 92022

    Standard health inspection

    21 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Nov 23, 2022
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Nov 23, 2022
    • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Nov 23, 2022
    • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Nov 23, 2022
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 23, 2022
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Nov 23, 2022
    • 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 ENo actual harm, potential for moreCorrected Nov 23, 2022
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Nov 23, 2022
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Nov 23, 2022
    • 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 Nov 23, 2022
    • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • 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 Nov 23, 2022
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Nov 23, 2022
    • 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 Nov 23, 2022
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Nov 23, 2022

    Enforcement Action

    Civil money penalty, $17,020 imposed December 2, 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 9, 2022, the nearest before the penalty date.

    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

   Citation F921, Cited in Six Inspections

   Inspectors cited F921 in September 2022, December 2023, July 2024, December 2024, October 2025 and April 2026. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242424242424252526F921 across all 12 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Five Inspections

   Inspectors cited F684 in September 2022, July 2024, December 2024, October 2025 and April 2026. 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.

   222324242424242424252526F684 across all 12 inspections, oldest to newest
3. 3

   Infection Control, Cited in Five Inspections

   Inspectors cited F880 in September 2022, September 2024, September 2024, March 2025 and October 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242424242424252526F880 across all 12 inspections, oldest to newest
4. 4

   Significant Medication Errors, Cited in Four Inspections

   Inspectors cited F760 in March 2024, May 2024, September 2024 and December 2024. 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.

   222324242424242424252526F760 across all 12 inspections, oldest to newest
5. 5

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in September 2022, March 2024, September 2024 and April 2026. This citation covers whether resident records are complete, accurate and kept confidential. 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.

   222324242424242424252526F842 across all 12 inspections, oldest to newest
6. 6

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in May 2024, July 2024 and April 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.

   222324242424242424252526F550 across all 12 inspections, oldest to newest
7. 7

   Help With Daily Living, Cited in Three Inspections

   Inspectors cited F677 in September 2024, December 2024 and April 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242424242424252526F677 across all 12 inspections, oldest to newest
8. 8

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in September 2022, December 2024 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

   222324242424242424252526F686 across all 12 inspections, oldest to newest
9. 9

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in September 2022, February 2024 and April 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. 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.

   222324242424242424252526F689 across all 12 inspections, oldest to newest
10. 10

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in September 2022, September 2024 and March 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.

    222324242424242424252526F761 across all 12 inspections, oldest to newest
11. 11

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in September 2022, December 2024 and April 2026. 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.

    222324242424242424252526F812 across all 12 inspections, oldest to newest
12. 12

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in October 2025 and April 2026. 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.

    222324242424242424252526F558 across all 12 inspections, oldest to newest
13. 13

    Citation F660, Cited in Two Inspections

    Inspectors cited F660 in September 2022 and December 2024. The agency describes it this way: Plan the resident's discharge to meet the resident's goals and needs. 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.

    222324242424242424252526F660 across all 12 inspections, oldest to newest
14. 14

    Mobility and Range of Motion, Cited in Two Inspections

    Inspectors cited F688 in September 2022 and April 2026. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242424242424252526F688 across all 12 inspections, oldest to newest
15. 15

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in October 2025 and April 2026. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242424242424252526F692 across all 12 inspections, oldest to newest
16. 16

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in September 2022 and October 2025. 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.

    222324242424242424252526F695 across all 12 inspections, oldest to newest
17. 17

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in September 2022 and April 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242424242424252526F756 across all 12 inspections, oldest to newest
18. 18

    Citation F868, Cited in Two Inspections

    Inspectors cited F868 in September 2022 and April 2026. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242424242424252526F868 across all 12 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 after F921 was cited, and how do you check it now?

   Citation F921: cited in six inspections, most seriously at level F.

2. 02

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

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

3. 03

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

   Infection Control: cited in five inspections, most seriously at level F.

4. 04

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

   Significant Medication Errors: cited in four inspections, most seriously at level D.

5. 05

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

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

6. 06

   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.

7. 07

   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 three inspections, most seriously at level D.

8. 08

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

   Pressure Injury Care: cited in three inspections, most seriously at level J.

9. 09

   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 three inspections, most seriously at level D.

10. 10

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

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

11. 11

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

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

12. 12

    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.

13. 13

    What changed after F660 was cited, and how do you check it now?

    Citation F660: cited in two inspections, most seriously at level D.

14. 14

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

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

15. 15

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

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

16. 16

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

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

17. 17

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

    Citation F756: cited in two inspections, most seriously at level D.

18. 18

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

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

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 September 2022.

20. 20

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

    A $17,020 civil money penalty was imposed December 2, 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 Ohio state survey agency.

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

  Ohio state survey agency

  Inspection Sep 9, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Dec 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)

  Ohio state survey agency

  Inspection Feb 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Mar 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection May 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Sep 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Sep 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)

  Ohio state survey agency

  Inspection Dec 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)

  Ohio state survey agency

  Inspection Mar 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection Oct 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)

  Ohio state survey agency

  Inspection Apr 29, 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 · 365825

  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.