The Vardell Report.Avir at Patriot

Across 20 inspections from May 2023 to August 2026, state surveyors documented 76 findings at Avir at Patriot; 76 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

20

2023–2026, complaint and standard

Findings

76

Deficiencies cited by state inspectors

Corrected

76

Of 76 findings, with a recorded correction date

Penalties

3

3 fines; 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. Aug 202026

   Complaint investigation

   1 finding

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 21, 2026

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

2. Jul 232026

   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 Aug 11, 2026

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

3. Mar 122026

   Complaint investigation

   7 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Mar 13, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Mar 13, 2026
   • 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 Mar 13, 2026
   • 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 Mar 13, 2026
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Mar 13, 2026
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Mar 13, 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 Mar 13, 2026

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

4. Nov 252025

   Complaint investigation

   3 findings

   • 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 Nov 26, 2025
   • 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 Nov 26, 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 Nov 26, 2025

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

5. Aug 292025

   Standard health inspection

   8 findings

   The same visit included a complaint investigation.

   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Aug 30, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Aug 30, 2025
   • 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 Aug 30, 2025
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Aug 30, 2025
   • 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 Aug 30, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 30, 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 DNo actual harm, potential for moreCorrected Aug 30, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 30, 2025

   Enforcement Action

   Civil money penalty, $82,469 imposed March 12, 2026. 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 August 29, 2025, the nearest before the penalty date.

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

6. Aug 82025

   Complaint investigation

   3 findings

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 9, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Aug 9, 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 Aug 9, 2025

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

7. Apr 222025

   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 Apr 23, 2025

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

8. Mar 252025

   Complaint investigation

   3 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Feb 27, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • 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 DNo actual harm, potential for moreCorrected Mar 26, 2025

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

9. Dec 122024

   Complaint investigation

   3 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Dec 13, 2024
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level ENo actual harm, potential for moreCorrected Dec 13, 2024
   • 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 Dec 13, 2024

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

10. Oct 312024

    Complaint investigation

    1 finding

    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 1, 2024

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

11. Aug 132024

    Complaint investigation

    2 findings

    • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Aug 14, 2024
    • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level ENo actual harm, potential for moreCorrected Aug 14, 2024

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

12. Aug 52024

    Complaint investigation

    3 findings

    • 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 Aug 6, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 6, 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 Aug 6, 2024

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

13. Jul 192024

    Standard health inspection

    11 findings

    • 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 Jul 20, 2024
    • 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 Jul 20, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jul 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 Jul 20, 2024
    • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level BPotential for minimal harmCorrected Jul 20, 2024

    Enforcement Action

    Civil money penalty, $10,509 imposed March 25, 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 19, 2024, the nearest before the penalty date.

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

14. Jul 102024

    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 Apr 22, 2024

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

15. Apr 232024

    Complaint investigation

    6 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 May 14, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 14, 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 May 14, 2024
    • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected May 14, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 14, 2024
    • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level DNo actual harm, potential for moreCorrected May 14, 2024

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

16. Mar 182024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Apr 5, 2024

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

17. Dec 222023

    Complaint investigation

    5 findings

    • 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 2, 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 Jan 5, 2024
    • 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 Jan 5, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 16, 2024
    • 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 ENo actual harm, potential for moreCorrected Jan 12, 2024

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

18. Nov 172023

    Complaint investigation

    2 findings

    • 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 24, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 24, 2023

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

19. Oct 132023

    Complaint investigation

    3 findings

    • 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 Oct 26, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 26, 2023
    • 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 Oct 23, 2023

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

20. May 242023

    Standard health inspection

    11 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 21, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 22, 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 ENo actual harm, potential for moreCorrected Jun 23, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jun 21, 2023
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jun 23, 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 Jun 16, 2023
    • 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 May 29, 2023
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jun 23, 2023
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jun 21, 2023
    • 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 Jun 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 Jun 23, 2023

    Enforcement Action

    Civil money penalty, $15,808 imposed July 10, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 24, 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

   Infection Control, Cited in Seven Inspections

   Inspectors cited F880 in October 2023, November 2023, December 2023, April 2024, July 2024, August 2025 and August 2025. 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.

   2323232324242424242424242525252525262626F880 across all 20 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in May 2023, April 2024, July 2024, July 2024, December 2024 and March 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.

   2323232324242424242424242525252525262626F689 across all 20 inspections, oldest to newest
3. 3

   Medical Records, Cited in Five Inspections

   Inspectors cited F842 in October 2023, August 2024, August 2025, November 2025 and March 2026. This citation covers whether resident records are complete, accurate and kept confidential. 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.

   2323232324242424242424242525252525262626F842 across all 20 inspections, oldest to newest
4. 4

   Respiratory Care, Cited in Four Inspections

   Inspectors cited F695 in May 2023, July 2024, August 2024 and August 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323232324242424242424242525252525262626F695 across all 20 inspections, oldest to newest
5. 5

   Grievances, Cited in Three Inspections

   Inspectors cited F585 in August 2025, November 2025 and March 2026. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. 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.

   2323232324242424242424242525252525262626F585 across all 20 inspections, oldest to newest
6. 6

   Coordinating Mental Health Screening, Cited in Three Inspections

   Inspectors cited F644 in April 2024, April 2025 and July 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. 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.

   2323232324242424242424242525252525262626F644 across all 20 inspections, oldest to newest
7. 7

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in November 2023, December 2023 and August 2024. 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.

   2323232324242424242424242525252525262626F656 across all 20 inspections, oldest to newest
8. 8

   Pharmacy Services, Cited in Three Inspections

   Inspectors cited F755 in May 2023, December 2023 and March 2026. 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.

   2323232324242424242424242525252525262626F755 across all 20 inspections, oldest to newest
9. 9

   Dignity and Resident Rights, Cited in Two Inspections

   Inspectors cited F550 in April 2024 and December 2024. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.

   2323232324242424242424242525252525262626F550 across all 20 inspections, oldest to newest
10. 10

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in July 2024 and August 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. 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.

    2323232324242424242424242525252525262626F558 across all 20 inspections, oldest to newest
11. 11

    Telling Families About Changes, Cited in Two Inspections

    Inspectors cited F580 in November 2025 and March 2026. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232324242424242424242525252525262626F580 across all 20 inspections, oldest to newest
12. 12

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in October 2024 and August 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.

    2323232324242424242424242525252525262626F610 across all 20 inspections, oldest to newest
13. 13

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in May 2023 and October 2023. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. 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.

    2323232324242424242424242525252525262626F623 across all 20 inspections, oldest to newest
14. 14

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in May 2023 and August 2025. 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.

    2323232324242424242424242525252525262626F677 across all 20 inspections, oldest to newest
15. 15

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in March 2024 and March 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2323232324242424242424242525252525262626F684 across all 20 inspections, oldest to newest
16. 16

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in April 2024 and August 2025. 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.

    2323232324242424242424242525252525262626F686 across all 20 inspections, oldest to newest
17. 17

    Continence and Catheter Care, Cited in Two Inspections

    Inspectors cited F690 in December 2023 and August 2025. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

    2323232324242424242424242525252525262626F690 across all 20 inspections, oldest to newest
18. 18

    Citation F693, Cited in Two Inspections

    Inspectors cited F693 in May 2023 and July 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.

    2323232324242424242424242525252525262626F693 across all 20 inspections, oldest to newest
19. 19

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in May 2023 and July 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. 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.

    2323232324242424242424242525252525262626F758 across all 20 inspections, oldest to newest
20. 20

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in May 2023 and July 2024. 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.

    2323232324242424242424242525252525262626F812 across all 20 inspections, oldest to newest
21. 21

    Keep all essential equipment working safely, Cited in Two Inspections

    Inspectors cited F908 in July 2024 and August 2025. The agency describes it this way: Keep all essential equipment working safely. 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.

    2323232324242424242424242525252525262626F908 across all 20 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

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

   Infection Control: cited in seven 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 six inspections, most seriously at level J.

3. 03

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

   Medical Records: cited in five inspections, most seriously at level E.

4. 04

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

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

5. 05

   How do we file a grievance, who answers it, and how quickly?

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

6. 06

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

   Coordinating Mental Health Screening: cited in three inspections, most seriously at level D.

7. 07

   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.

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 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 E.

10. 10

    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 E.

11. 11

    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 E.

12. 12

    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.

13. 13

    When do you transfer or discharge a resident, and how much notice do families get?

    Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.

14. 14

    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.

15. 15

    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 two inspections, most seriously at level J.

16. 16

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

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

17. 17

    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.

18. 18

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

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

19. 19

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

20. 20

    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.

21. 21

    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.

22. 22

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in May 2023.

23. 23

    What led to the 2026 fine, and has it been paid?

    An $82,469 civil money penalty was imposed March 12, 2026. CMS publishes the fine, not whether it has been paid. The record holds three 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 May 24, 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 Oct 13, 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 Nov 17, 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 22, 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 Mar 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Texas state survey agency

  Inspection Apr 23, 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 Jul 10, 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 Jul 19, 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 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)

  Texas state survey agency

  Inspection Aug 13, 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 31, 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 Dec 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 Mar 25, 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 Apr 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)

  Texas state survey agency

  Inspection Aug 8, 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 Aug 29, 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 Nov 25, 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 Mar 12, 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 23, 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 Aug 20, 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 · 676468

  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.