The Vardell Report.Twin Lakes Rehabilitation and Healthcare Center

Across 16 inspections from October 2023 to May 2026, state surveyors documented 77 findings at Twin Lakes Rehabilitation and Healthcare Center; 77 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

16

2023–2026, complaint and standard

Findings

77

Deficiencies cited by state inspectors

Corrected

77

Of 77 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. May 142026

   Complaint investigation

   5 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jun 24, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 24, 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 May 8, 2026
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected May 8, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 24, 2026

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

2. Apr 172026

   Complaint investigation

   2 findings

   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected May 14, 2026
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected May 14, 2026

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

3. Feb 42026

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 17, 2026

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

4. Jan 22026

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Jan 22, 2026
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Jan 22, 2026

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

5. Nov 202025

   Standard health inspection

   12 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jan 7, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jan 7, 2026
   • 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 Jan 7, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 7, 2026
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Jan 7, 2026
   • 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 7, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jan 7, 2026
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jan 7, 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 Nov 12, 2025
   • 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 7, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 11, 2026
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Jan 7, 2026

   Enforcement Action

   Civil money penalty, $18,873 imposed November 20, 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 November 20, 2025, the nearest before the penalty date.

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

6. May 142025

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 12, 2025

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

7. Apr 302025

   Complaint investigation

   1 finding

   • 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 May 28, 2025

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

8. Dec 32024

   Complaint investigation

   2 findings

   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Jan 7, 2025
   • 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 7, 2025

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

9. Oct 92024

   Standard health inspection

   25 findings

   The same visit included a complaint investigation.

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Nov 19, 2024
   • 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 19, 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 ENo actual harm, potential for moreCorrected Nov 19, 2024
   • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level ENo actual harm, potential for moreCorrected Nov 19, 2024
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected Nov 19, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • 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 Nov 19, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Sep 1, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • 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 19, 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 Nov 19, 2024
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Nov 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 Nov 19, 2024
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • 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 Nov 19, 2024

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

10. Sep 112024

    Complaint investigation

    3 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 DNo actual harm, potential for moreCorrected Oct 9, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 9, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 9, 2024

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

11. Jul 32024

    Complaint investigation

    3 findings

    • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level ENo actual harm, potential for moreCorrected Aug 20, 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 Aug 20, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 20, 2024

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

12. May 302024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 19, 2024

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

13. May 12024

    Complaint investigation

    1 finding

    • 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 May 23, 2024

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

14. Mar 52024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 28, 2024

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

15. Nov 92023

    Standard health inspection

    15 findings

    The same visit included a complaint investigation.

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • 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 Dec 27, 2023
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 27, 2023
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 27, 2023
    • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Dec 27, 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 Dec 27, 2023

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

16. Oct 32023

    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 Oct 26, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 26, 2023

    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

   Quality of Care, Cited in Six Inspections

   Inspectors cited F684 in November 2023, March 2024, May 2024, October 2024, May 2025 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.

   23232424242424242425252526262626F684 across all 16 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in July 2024, November 2025, January 2026 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242425252526262626F689 across all 16 inspections, oldest to newest
3. 3

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in November 2023, July 2024, September 2024 and May 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.

   23232424242424242425252526262626F880 across all 16 inspections, oldest to newest
4. 4

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in November 2023, October 2024 and November 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242425252526262626F656 across all 16 inspections, oldest to newest
5. 5

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in November 2023, October 2024 and November 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242424242425252526262626F657 across all 16 inspections, oldest to newest
6. 6

   Professional Standards, Cited in Three Inspections

   Inspectors cited F658 in October 2024, November 2025 and May 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.

   23232424242424242425252526262626F658 across all 16 inspections, oldest to newest
7. 7

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in November 2023, September 2024 and February 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

   23232424242424242425252526262626F686 across all 16 inspections, oldest to newest
8. 8

   Pharmacy Services, Cited in Three Inspections

   Inspectors cited F755 in November 2023, May 2024 and November 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.

   23232424242424242425252526262626F755 across all 16 inspections, oldest to newest
9. 9

   Medical Records, Cited in Three Inspections

   Inspectors cited F842 in November 2023, October 2024 and April 2025. 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.

   23232424242424242425252526262626F842 across all 16 inspections, oldest to newest
10. 10

    Citation F867, Cited in Three Inspections

    Inspectors cited F867 in November 2023, October 2024 and November 2025. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. 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.

    23232424242424242425252526262626F867 across all 16 inspections, oldest to newest
11. 11

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in October 2024 and November 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.

    23232424242424242425252526262626F558 across all 16 inspections, oldest to newest
12. 12

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in October 2023 and September 2024. 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.

    23232424242424242425252526262626F584 across all 16 inspections, oldest to newest
13. 13

    Citation F636, Cited in Two Inspections

    Inspectors cited F636 in November 2023 and November 2025. The agency describes it this way: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. 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.

    23232424242424242425252526262626F636 across all 16 inspections, oldest to newest
14. 14

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in November 2023 and October 2024. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242425252526262626F641 across all 16 inspections, oldest to newest
15. 15

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in October 2023 and October 2024. 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.

    23232424242424242425252526262626F677 across all 16 inspections, oldest to newest
16. 16

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in November 2023 and October 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242424242425252526262626F693 across all 16 inspections, oldest to newest
17. 17

    Citation F810, Cited in Two Inspections

    Inspectors cited F810 in October 2024 and May 2026. The agency describes it this way: Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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.

    23232424242424242425252526262626F810 across all 16 inspections, oldest to newest
18. 18

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in November 2023 and November 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.

    23232424242424242425252526262626F812 across all 16 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 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 six inspections, most seriously at level E.

2. 02

   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 K.

3. 03

   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.

4. 04

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

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

5. 05

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

   Care Plan Timing and Review: cited in three inspections, most seriously at level D.

6. 06

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

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

7. 07

   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 D.

8. 08

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

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

9. 09

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

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

10. 10

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in three inspections, most seriously at level E.

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

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

13. 13

    What changed after F636 was cited, and how do you check it now?

    Citation F636: cited in two inspections, most seriously at level D.

14. 14

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

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

15. 15

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level E.

16. 16

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

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

17. 17

    What changed after F810 was cited, and how do you check it now?

    Citation F810: cited in two inspections, most seriously at level D.

18. 18

    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.

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?

    An $18,873 civil money penalty was imposed November 20, 2025. 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 Pennsylvania state survey agency.

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

  Pennsylvania state survey agency

  Inspection Oct 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Nov 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Mar 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)

  Pennsylvania state survey agency

  Inspection May 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)

  Pennsylvania 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)

  Pennsylvania state survey agency

  Inspection Jul 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)

  Pennsylvania 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)

  Pennsylvania state survey agency

  Inspection Oct 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Dec 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)

  Pennsylvania state survey agency

  Inspection Apr 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)

  Pennsylvania state survey agency

  Inspection May 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)

  Pennsylvania state survey agency

  Inspection Nov 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Jan 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Feb 4, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection Apr 17, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Pennsylvania state survey agency

  Inspection May 14, 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 · 395500

  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.