The Vardell Report.Arbor View Nursing & Rehabilitation

Across 15 inspections from April 2023 to September 2026, state surveyors documented 81 findings at Arbor View Nursing & Rehabilitation; 70 have a recorded correction and 11 await one; CMS lists 6 enforcement actions in the window.

Inspections

15

2023–2026, standard and complaint

Findings

81

Deficiencies cited by state inspectors

Corrected

70

Of 81 findings, with a recorded correction date

Penalties

6

5 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Sep 42026

   Standard health inspection

   11 findings

   • 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 moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction

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

2. Jul 292026

   Complaint investigation

   1 finding

   • 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 Aug 18, 2026

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

3. Jul 32026

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Aug 4, 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 Aug 4, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 4, 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 Aug 4, 2026

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

4. Jun 182026

   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 Jul 15, 2026

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

5. Sep 72025

   Complaint investigation

   3 findings

   • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Sep 8, 2025
   • 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 Sep 8, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Sep 8, 2025

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

6. Jul 312025

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level KImmediate jeopardyCorrected Sep 8, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Sep 8, 2025
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Sep 8, 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 Sep 8, 2025
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Sep 8, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Sep 8, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
   • F729Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 8, 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 Sep 8, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 8, 2025

   Enforcement Action

   Civil money penalty, $91,293 imposed July 31, 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 July 31, 2025, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed July 31, 2025. Status: Closed, September 8, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 31, 2025, the nearest before the penalty date.

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

7. Jun 122025

   Complaint investigation

   6 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 ENo actual harm, potential for moreCorrected Jul 8, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jul 8, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level DNo actual harm, potential for moreCorrected Jul 8, 2025
   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level DNo actual harm, potential for moreCorrected Jul 8, 2025

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

8. Feb 282025

   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 Apr 1, 2025

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

9. Oct 122024

   Complaint investigation

   2 findings

   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Oct 13, 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 Oct 13, 2024

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

10. May 72024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 8, 2024

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

11. Mar 142024

    Complaint investigation

    3 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 15, 2024
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Mar 12, 2024

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

12. Mar 72024

    Complaint investigation

    1 finding

    • 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 8, 2024

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

13. Jan 222024

    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 KImmediate jeopardyCorrected Jan 23, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Jan 23, 2024
    • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Jan 23, 2024

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

14. Dec 212023

    Complaint investigation

    7 findings

    The same visit included an infection control inspection.

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Oct 26, 2023
    • 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 Dec 22, 2023
    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Dec 22, 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 22, 2023
    • 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 Dec 22, 2023
    • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected Dec 22, 2023
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Dec 22, 2023

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

15. Apr 272023

    Standard health inspection

    17 findings

    • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected May 22, 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 May 22, 2023
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected May 22, 2023
    • 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 May 22, 2023
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 22, 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 May 22, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected May 22, 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 May 22, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected May 22, 2023
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected May 22, 2023

    Enforcement Action

    Civil money penalty, $15,593 imposed December 21, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $21,528 imposed December 21, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $14,814 imposed May 7, 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 April 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $11,389 imposed June 14, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 27, 2023, 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

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in December 2023, May 2024, June 2025, July 2025, June 2026 and July 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.

   232324242424242525252526262626F689 across all 15 inspections, oldest to newest
2. 2

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in April 2023, October 2024 and June 2025. 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.

   232324242424242525252526262626F550 across all 15 inspections, oldest to newest
3. 3

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in January 2024, July 2025 and July 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242525252526262626F609 across all 15 inspections, oldest to newest
4. 4

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in April 2023, July 2025 and July 2026. 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.

   232324242424242525252526262626F656 across all 15 inspections, oldest to newest
5. 5

   Significant Medication Errors, Cited in Three Inspections

   Inspectors cited F760 in April 2023, July 2025 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.

   232324242424242525252526262626F760 across all 15 inspections, oldest to newest
6. 6

   Citation F925, Cited in Three Inspections

   Inspectors cited F925 in April 2023, March 2024 and July 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242525252526262626F925 across all 15 inspections, oldest to newest
7. 7

   A Clean, Homelike Setting, Cited in Two Inspections

   Inspectors cited F584 in January 2024 and July 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   232324242424242525252526262626F584 across all 15 inspections, oldest to newest
8. 8

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in December 2023 and July 2025. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

   232324242424242525252526262626F600 across all 15 inspections, oldest to newest
9. 9

   Investigating Alleged Violations, Cited in Two Inspections

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

   232324242424242525252526262626F610 across all 15 inspections, oldest to newest
10. 10

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in April 2023 and July 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242525252526262626F641 across all 15 inspections, oldest to newest
11. 11

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in December 2023 and September 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.

    232324242424242525252526262626F755 across all 15 inspections, oldest to newest
12. 12

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in December 2023 and July 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.

    232324242424242525252526262626F761 across all 15 inspections, oldest to newest
13. 13

    Garbage and Refuse, Cited in Two Inspections

    Inspectors cited F814 in April 2023 and March 2024. This citation covers whether garbage and refuse are disposed of properly. 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.

    232324242424242525252526262626F814 across all 15 inspections, oldest to newest
14. 14

    Citation F552, No Recorded Correction

    F552 was cited in September 2026. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F552 across all 15 inspections, oldest to newest
15. 15

    Citation F628, No Recorded Correction

    F628 was cited in September 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. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F628 across all 15 inspections, oldest to newest
16. 16

    Citation F635, No Recorded Correction

    F635 was cited in September 2026. The agency describes it this way: Provide doctor's orders for the resident's immediate care at the time the resident was admitted. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F635 across all 15 inspections, oldest to newest
17. 17

    Coordinating Mental Health Screening, No Recorded Correction

    F644 was cited in March 2024 and September 2026. This citation covers whether assessments are coordinated with the state’s pre-admission screening for mental illness and intellectual disability (PASARR), and referrals made. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F644 across all 15 inspections, oldest to newest
18. 18

    The First 48 Hours, No Recorded Correction

    F655 was cited in September 2026. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F655 across all 15 inspections, oldest to newest
19. 19

    Continence and Catheter Care, No Recorded Correction

    F690 was cited in April 2023 and September 2026. This citation covers continence care, catheter care and preventing urinary tract infections. The most serious was level E (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F690 across all 15 inspections, oldest to newest
20. 20

    Citation F727, No Recorded Correction

    F727 was cited in December 2023, July 2025 and September 2026. The agency describes it this way: Have 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. The most serious was level F (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F727 across all 15 inspections, oldest to newest
21. 21

    Kitchen and Food Safety, No Recorded Correction

    F812 was cited in April 2023, March 2024, July 2025 and September 2026. This citation covers how food is stored, prepared and served. The most serious was level F (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F812 across all 15 inspections, oldest to newest
22. 22

    Medical Records, No Recorded Correction

    F842 was cited in April 2023, February 2025, June 2025, July 2025, September 2025 and September 2026. This citation covers whether resident records are complete, accurate and kept confidential. The most serious was level E (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F842 across all 15 inspections, oldest to newest
23. 23

    Infection Control, No Recorded Correction

    F880 was cited in April 2023, July 2025 and September 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level E (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F880 across all 15 inspections, oldest to newest
24. 24

    Keep all essential equipment working safely, No Recorded Correction

    F908 was cited in January 2024 and September 2026. The agency describes it this way: Keep all essential equipment working safely. The most serious was level E (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242424242525252526262626F908 across all 15 inspections, oldest to newest

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

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in six inspections, most seriously at level K.

2. 02

   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.

3. 03

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in three inspections, most seriously at level 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 E.

5. 05

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

   Significant Medication Errors: cited in three inspections, most seriously at level J.

6. 06

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

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

7. 07

   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 K.

8. 08

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

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level K.

9. 09

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

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

10. 10

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

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

11. 11

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

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

12. 12

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

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

13. 13

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in two inspections, most seriously at level E.

14. 14

    What changed after F552 was cited, and how do you check it now?

    Citation F552: cited in one inspections, most seriously at level D. The September 4, 2026 citation has no recorded correction date.

15. 15

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

    Citation F628: cited in one inspections, most seriously at level D. The September 4, 2026 citation has no recorded correction date.

16. 16

    What changed after F635 was cited, and how do you check it now?

    Citation F635: cited in one inspections, most seriously at level D. The September 4, 2026 citation has no recorded correction date.

17. 17

    How do you arrange services for residents with a mental illness or an intellectual disability?

    Coordinating Mental Health Screening: cited in two inspections, most seriously at level D. The September 4, 2026 citation has no recorded correction date.

18. 18

    What happens in the first 48 hours after admission, and who writes the first care plan?

    The First 48 Hours: cited in one inspections, most seriously at level D. The September 4, 2026 citation has no recorded correction date.

19. 19

    How is continence care scheduled, and how do you prevent urinary infections?

    Continence and Catheter Care: cited in two inspections, most seriously at level E. The September 4, 2026 citation has no recorded correction date.

20. 20

    What changed after F727 was cited, and how do you check it now?

    Citation F727: cited in three inspections, most seriously at level F. The September 4, 2026 citation has no recorded correction date.

21. 21

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

    Kitchen and Food Safety: cited in four inspections, most seriously at level F. The September 4, 2026 citation has no recorded correction date.

22. 22

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

    Medical Records: cited in six inspections, most seriously at level E. The September 4, 2026 citation has no recorded correction date.

23. 23

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

    Infection Control: cited in three inspections, most seriously at level E. The September 4, 2026 citation has no recorded correction date.

24. 24

    What changed after F908 was cited, and how do you check it now?

    Keep all essential equipment working safely: cited in two inspections, most seriously at level E. The September 4, 2026 citation has no recorded correction date.

25. 25

    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.

26. 26

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

    A $91,293 civil money penalty was imposed July 31, 2025. CMS publishes the fine, not whether it has been paid. The record holds six enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.

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

  Texas state survey agency

  Inspection Apr 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)

  Texas state survey agency

  Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Jan 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Mar 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)

  Texas state survey agency

  Inspection Mar 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection May 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)

  Texas state survey agency

  Inspection Oct 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Feb 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)

  Texas state survey agency

  Inspection Jun 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)

  Texas state survey agency

  Inspection Jul 31, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Sep 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Jun 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

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

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

  Texas state survey agency

  Inspection Jul 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Sep 4, 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 · 455724

  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.