The Vardell Report.Sapphire Rehabilitation and Care Center

Across 17 inspections from February 2020 to August 2026, state surveyors documented 91 findings at Sapphire Rehabilitation and Care Center; 91 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

17

2020–2026, complaint and standard

Findings

91

Deficiencies cited by state inspectors

Corrected

91

Of 91 findings, with a recorded correction date

Penalties

4

2 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. Aug 132026

   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 Aug 18, 2026

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

2. Jun 162026

   Complaint investigation

   1 finding

   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreCorrected Jun 26, 2026

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

3. Jun 92026

   Complaint investigation

   2 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 Jun 15, 2026
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Jun 15, 2026

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

4. May 112026

   Complaint investigation

   2 findings

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 15, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 15, 2026

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

5. Mar 192026

   Complaint investigation

   1 finding

   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Apr 2, 2026

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

6. Jan 282026

   Complaint investigation

   1 finding

   • 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 Feb 3, 2026

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

7. Dec 112025

   Complaint investigation

   10 findings

   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Jan 1, 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 Jan 1, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level FNo actual harm, potential for moreCorrected Jan 1, 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 ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jan 1, 2026

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

8. Nov 142025

   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 Jan 1, 2026

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

9. Sep 222025

   Standard health inspection

   32 findings

   The same visit included a complaint investigation.

   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level JImmediate jeopardyCorrected Jan 1, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jan 1, 2026
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level GActual harmCorrected Jan 1, 2026
   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level FNo actual harm, potential for moreCorrected Jan 1, 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 Jan 1, 2026
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Jan 1, 2026
   • F570Assure the security of all personal funds of residents deposited with the facility.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • 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 Jan 1, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jan 1, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jan 1, 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 Jan 1, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.Level DNo actual harm, potential for moreCorrected Jan 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 Jan 1, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 1, 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 1, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Jan 1, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level CPotential for minimal harmCorrected Jan 1, 2026

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

10. Jun 232025

    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 GActual harmCorrected Jun 24, 2025

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

11. May 122025

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jun 23, 2025

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

12. Mar 42025

    Complaint investigation

    4 findings

    The same visit included an infection control inspection.

    • 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 Mar 21, 2025
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 21, 2025
    • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Mar 21, 2025
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 21, 2025

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

13. Aug 52024

    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 Aug 16, 2024

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

14. May 302024

    Complaint investigation

    3 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 14, 2024
    • 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 May 22, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 14, 2024

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

15. Feb 12024

    Complaint investigation

    7 findings

    • 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 Feb 22, 2024
    • 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 Feb 22, 2024
    • 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 Feb 22, 2024
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Feb 22, 2024

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

16. Jun 272023

    Standard health inspection

    10 findings

    • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Jul 11, 2023
    • F791Provide or obtain dental services for each resident.Level JImmediate jeopardyCorrected Jul 11, 2023
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • 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 Jul 11, 2023
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jul 11, 2023
    • F730Observe each nurse aide's job performance and give regular training.Level CPotential for minimal harmCorrected Jul 11, 2023

    Enforcement Action

    Civil money penalty, $64,333 imposed May 12, 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 June 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed May 12, 2025. Status: Closed, June 24, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $177,412 imposed September 11, 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 June 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed September 11, 2025. Status: Closed, January 1, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 27, 2023, the nearest before the penalty date.

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

17. Feb 272020

    Standard health inspection

    13 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 27, 2020
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 27, 2020
    • 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 Mar 27, 2020
    • 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 Mar 27, 2020
    • 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 Mar 27, 2020
    • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
    • 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 Mar 27, 2020
    • 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 Mar 27, 2020
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
    • 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 Mar 27, 2020
    • 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 Mar 27, 2020

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

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

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

1. 1

   Help With Daily Living, Cited in Five Inspections

   Inspectors cited F677 in February 2020, March 2025, September 2025, December 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.

   2023242424252525252525262626262626F677 across all 17 inspections, oldest to newest
2. 2

   Infection Control, Cited in Five Inspections

   Inspectors cited F880 in February 2020, May 2024, March 2025, September 2025 and May 2026. 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.

   2023242424252525252525262626262626F880 across all 17 inspections, oldest to newest
3. 3

   Citation F921, Cited in Five Inspections

   Inspectors cited F921 in June 2023, February 2024, September 2025, December 2025 and August 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.

   2023242424252525252525262626262626F921 across all 17 inspections, oldest to newest
4. 4

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in February 2020, May 2024, September 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.

   2023242424252525252525262626262626F689 across all 17 inspections, oldest to newest
5. 5

   Kitchen and Food Safety, Cited in Four Inspections

   Inspectors cited F812 in February 2020, February 2024, September 2025 and December 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2023242424252525252525262626262626F812 across all 17 inspections, oldest to newest
6. 6

   Needs and Preferences, Cited in Three Inspections

   Inspectors cited F558 in June 2023, September 2025 and December 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.

   2023242424252525252525262626262626F558 across all 17 inspections, oldest to newest
7. 7

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in March 2025, December 2025 and June 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2023242424252525252525262626262626F584 across all 17 inspections, oldest to newest
8. 8

   Investigating Alleged Violations, Cited in Three Inspections

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

   2023242424252525252525262626262626F610 across all 17 inspections, oldest to newest
9. 9

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in May 2024, May 2025 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.

   2023242424252525252525262626262626F684 across all 17 inspections, oldest to newest
10. 10

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in February 2020, September 2025 and December 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.

    2023242424252525252525262626262626F761 across all 17 inspections, oldest to newest
11. 11

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in February 2020 and February 2024. 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.

    2023242424252525252525262626262626F550 across all 17 inspections, oldest to newest
12. 12

    Telling Families About Changes, Cited in Two Inspections

    Inspectors cited F580 in February 2020 and August 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. 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.

    2023242424252525252525262626262626F580 across all 17 inspections, oldest to newest
13. 13

    Citation F627, Cited in Two Inspections

    Inspectors cited F627 in September 2025 and June 2026. The agency describes it this way: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. 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.

    2023242424252525252525262626262626F627 across all 17 inspections, oldest to newest
14. 14

    Citation F628, Cited in Two Inspections

    Inspectors cited F628 in September 2025 and January 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. 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.

    2023242424252525252525262626262626F628 across all 17 inspections, oldest to newest
15. 15

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in February 2020 and September 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.

    2023242424252525252525262626262626F656 across all 17 inspections, oldest to newest
16. 16

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in June 2023 and September 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

    2023242424252525252525262626262626F692 across all 17 inspections, oldest to newest
17. 17

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in June 2023 and September 2025. This citation covers whether residents are free from significant medication errors. 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.

    2023242424252525252525262626262626F760 across all 17 inspections, oldest to newest
18. 18

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in June 2023 and December 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

    2023242424252525252525262626262626F804 across all 17 inspections, oldest to newest

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

1. 01

   How 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.

2. 02

   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.

3. 03

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

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

4. 04

   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 four inspections, most seriously at level J.

5. 05

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

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

6. 06

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

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

7. 07

   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.

8. 08

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

   Investigating Alleged Violations: cited in three inspections, most seriously at level E.

9. 09

   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 J.

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 E.

11. 11

    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.

12. 12

    How quickly will we hear about a fall, an injury or a change in condition, and from whom?

    Telling Families About Changes: cited in two inspections, most seriously at level D.

13. 13

    What changed after F627 was cited, and how do you check it now?

    Citation F627: cited in two inspections, most seriously at level J.

14. 14

    What changed after F628 was cited, and how do you check it now?

    Citation F628: cited in two inspections, most seriously at level D.

15. 15

    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.

16. 16

    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 D.

17. 17

    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 J.

18. 18

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

    Food Quality and Temperature: 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?

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

20. 20

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

    A $177,412 civil money penalty was imposed September 11, 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 Ohio state survey agency.

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

  Ohio state survey agency

  Inspection Feb 27, 2020 · 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 Jun 27, 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 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Ohio state survey agency

  Inspection May 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)

  Ohio 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)

  Ohio state survey agency

  Inspection Mar 4, 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 May 12, 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 Jun 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)

  Ohio state survey agency

  Inspection Sep 22, 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 Nov 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)

  Ohio state survey agency

  Inspection Dec 11, 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 Jan 28, 2026 · 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 19, 2026 · 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 11, 2026 · 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 Jun 9, 2026 · 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 Jun 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)

  Ohio state survey agency

  Inspection Aug 13, 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 · 365950

  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.