The Vardell Report.Ashland Nursing and Rehabilitation

Across 8 inspections from February 2020 to July 2026, state surveyors documented 161 findings at Ashland Nursing and Rehabilitation; 161 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

8

2020–2026, complaint and standard

Findings

161

Deficiencies cited by state inspectors

Corrected

161

Of 161 findings, with a recorded correction date

Penalties

2

1 fine; 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. Jul 22026

   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 Jul 16, 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 Jun 10, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 16, 2026

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

2. Mar 182026

   Complaint investigation

   13 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Apr 29, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jul 2, 2026
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Jul 2, 2026
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Apr 29, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 29, 2026
   • 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 Jul 16, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 29, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 16, 2026
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level DNo actual harm, potential for moreCorrected Jul 2, 2026
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Jul 2, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Jul 2, 2026
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Jul 2, 2026
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jul 2, 2026

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

3. Aug 212025

   Complaint investigation

   37 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 17, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • 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 Nov 17, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • 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 Nov 17, 2025
   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Nov 17, 2025
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • 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 17, 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 Nov 17, 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 Nov 17, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Nov 17, 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 17, 2025
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Nov 17, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Nov 17, 2025

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

4. Apr 112024

   Complaint investigation

   8 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected May 7, 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 May 7, 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 May 7, 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 May 7, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 7, 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 DNo actual harm, potential for moreCorrected May 7, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected May 7, 2024
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected May 7, 2024

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

5. Feb 92024

   Standard health inspection

   65 findings

   The same visit included a complaint investigation.

   • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 2024
   • 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 Apr 11, 2024
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 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 ENo actual harm, potential for moreCorrected May 7, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 11, 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 Apr 11, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 7, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 2024
   • 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 Apr 11, 2024
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected May 7, 2024
   • 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 Apr 11, 2024
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 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 May 7, 2024
   • F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • 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 Apr 11, 2024
   • 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 Apr 11, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 11, 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 Apr 11, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F675Honor each resident's preferences, choices, values and beliefs.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 7, 2024
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Apr 11, 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 Apr 11, 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 DNo actual harm, potential for moreCorrected May 7, 2024
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Apr 11, 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 DNo actual harm, potential for moreCorrected May 7, 2024
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Apr 11, 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 DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Apr 11, 2024

   Enforcement Action

   Civil money penalty, $36,491 imposed March 18, 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 February 9, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed March 18, 2026. Status: Closed, July 16, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 9, 2024, the nearest before the penalty date.

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

6. Nov 202023

   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 Dec 19, 2023
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Dec 19, 2023
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 19, 2023

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

7. Jun 72022

   Standard health inspection

   13 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 Jul 12, 2022
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 12, 2022
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 12, 2022
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jul 12, 2022
   • 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 Jul 12, 2022
   • 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 Jul 12, 2022
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jul 12, 2022
   • F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level DNo actual harm, potential for moreCorrected Jul 12, 2022

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

8. Feb 62020

   Standard health inspection

   19 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Mar 10, 2020
   • 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 Mar 10, 2020
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Mar 10, 2020
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Mar 10, 2020
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Mar 10, 2020
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Mar 10, 2020
   • 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 Mar 10, 2020
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 10, 2020
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Mar 10, 2020
   • 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 Mar 10, 2020
   • 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 Mar 10, 2020
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 10, 2020
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 10, 2020
   • 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 Mar 10, 2020
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 10, 2020
   • 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 Mar 10, 2020
   • F836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 18, 2019
   • 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 Mar 10, 2020
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Mar 10, 2020

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

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

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

1. 1

   Telling Families About Changes, Cited in Six Inspections

   Inspectors cited F580 in February 2020, November 2023, February 2024, August 2025, March 2026 and July 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.

   2022232424252626F580 across all 8 inspections, oldest to newest
2. 2

   A Clean, Homelike Setting, Cited in Five Inspections

   Inspectors cited F584 in February 2020, June 2022, February 2024, August 2025 and March 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2022232424252626F584 across all 8 inspections, oldest to newest
3. 3

   Protection From Abuse and Neglect, Cited in Five Inspections

   Inspectors cited F600 in February 2020, February 2024, August 2025, March 2026 and July 2026. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

   2022232424252626F600 across all 8 inspections, oldest to newest
4. 4

   Care Plans, Cited in Four Inspections

   Inspectors cited F656 in February 2020, June 2022, February 2024 and August 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2022232424252626F656 across all 8 inspections, oldest to newest
5. 5

   Care Plan Timing and Review, Cited in Four Inspections

   Inspectors cited F657 in June 2022, February 2024, April 2024 and August 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2022232424252626F657 across all 8 inspections, oldest to newest
6. 6

   Professional Standards, Cited in Four Inspections

   Inspectors cited F658 in February 2020, February 2024, March 2026 and July 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.

   2022232424252626F658 across all 8 inspections, oldest to newest
7. 7

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in February 2020, June 2022, February 2024 and April 2024. 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.

   2022232424252626F684 across all 8 inspections, oldest to newest
8. 8

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in February 2020, February 2024, August 2025 and March 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 J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2022232424252626F689 across all 8 inspections, oldest to newest
9. 9

   Kitchen and Food Safety, Cited in Four Inspections

   Inspectors cited F812 in February 2020, June 2022, February 2024 and April 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.

   2022232424252626F812 across all 8 inspections, oldest to newest
10. 10

    Citation F607, Cited in Three Inspections

    Inspectors cited F607 in February 2024, August 2025 and March 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.

    2022232424252626F607 across all 8 inspections, oldest to newest
11. 11

    Help With Daily Living, Cited in Three Inspections

    Inspectors cited F677 in February 2020, February 2024 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.

    2022232424252626F677 across all 8 inspections, oldest to newest
12. 12

    Continence and Catheter Care, Cited in Three Inspections

    Inspectors cited F690 in February 2020, February 2024 and April 2024. 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.

    2022232424252626F690 across all 8 inspections, oldest to newest
13. 13

    Citation F730, Cited in Three Inspections

    Inspectors cited F730 in February 2024, April 2024 and August 2025. The agency describes it this way: Observe each nurse aide's job performance and give regular training. 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.

    2022232424252626F730 across all 8 inspections, oldest to newest
14. 14

    Citation F745, Cited in Three Inspections

    Inspectors cited F745 in June 2022, February 2024 and August 2025. The agency describes it this way: Provide medically-related social services to help each resident achieve the highest possible quality of life. 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.

    2022232424252626F745 across all 8 inspections, oldest to newest
15. 15

    Food Quality and Temperature, Cited in Three Inspections

    Inspectors cited F804 in June 2022, February 2024 and August 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

    2022232424252626F804 across all 8 inspections, oldest to newest
16. 16

    Citation F941, Cited in Three Inspections

    Inspectors cited F941 in February 2024, August 2025 and March 2026. The agency describes it this way: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. 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.

    2022232424252626F941 across all 8 inspections, oldest to newest
17. 17

    Citation F942, Cited in Three Inspections

    Inspectors cited F942 in February 2024, August 2025 and March 2026. The agency describes it this way: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. 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.

    2022232424252626F942 across all 8 inspections, oldest to newest
18. 18

    Citation F944, Cited in Three Inspections

    Inspectors cited F944 in February 2024, August 2025 and March 2026. The agency describes it this way: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. 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.

    2022232424252626F944 across all 8 inspections, oldest to newest
19. 19

    Citation F949, Cited in Three Inspections

    Inspectors cited F949 in February 2024, August 2025 and March 2026. The agency describes it this way: Provide behavior health training consistent with the requirements and as determined by a facility assessment. 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.

    2022232424252626F949 across all 8 inspections, oldest to newest
20. 20

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in June 2022 and February 2024. 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.

    2022232424252626F558 across all 8 inspections, oldest to newest
21. 21

    Reporting Suspected Abuse, Cited in Two Inspections

    Inspectors cited F609 in February 2024 and August 2025. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2022232424252626F609 across all 8 inspections, oldest to newest
22. 22

    Investigating Alleged Violations, Cited in Two Inspections

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

    2022232424252626F610 across all 8 inspections, oldest to newest
23. 23

    Citation F622, Cited in Two Inspections

    Inspectors cited F622 in February 2020 and February 2024. The agency describes it this way: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. 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.

    2022232424252626F622 across all 8 inspections, oldest to newest
24. 24

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in February 2020 and February 2024. 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.

    2022232424252626F623 across all 8 inspections, oldest to newest
25. 25

    Pre-Admission Screening, Cited in Two Inspections

    Inspectors cited F645 in June 2022 and February 2024. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). 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.

    2022232424252626F645 across all 8 inspections, oldest to newest
26. 26

    Provide activities to meet all resident's needs, Cited in Two Inspections

    Inspectors cited F679 in February 2024 and August 2025. The agency describes it this way: Provide activities to meet all resident's needs. 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.

    2022232424252626F679 across all 8 inspections, oldest to newest
27. 27

    Citation F680, Cited in Two Inspections

    Inspectors cited F680 in February 2024 and August 2025. The agency describes it this way: Ensure the activities program is directed by a qualified professional. 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.

    2022232424252626F680 across all 8 inspections, oldest to newest
28. 28

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in June 2022 and February 2024. This citation covers how the home prevents and treats pressure injuries (bedsores). 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.

    2022232424252626F686 across all 8 inspections, oldest to newest
29. 29

    Provide appropriate foot care, Cited in Two Inspections

    Inspectors cited F687 in February 2024 and August 2025. The agency describes it this way: Provide appropriate foot care. 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.

    2022232424252626F687 across all 8 inspections, oldest to newest
30. 30

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in February 2024 and April 2024. 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.

    2022232424252626F695 across all 8 inspections, oldest to newest
31. 31

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in February 2020 and February 2024. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. 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.

    2022232424252626F697 across all 8 inspections, oldest to newest
32. 32

    Citation F700, Cited in Two Inspections

    Inspectors cited F700 in February 2024 and April 2024. The agency describes it this way: Try 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. 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.

    2022232424252626F700 across all 8 inspections, oldest to newest
33. 33

    Nursing Staff Levels, Cited in Two Inspections

    Inspectors cited F725 in February 2024 and August 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. 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.

    2022232424252626F725 across all 8 inspections, oldest to newest
34. 34

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in February 2020 and November 2023. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary 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.

    2022232424252626F757 across all 8 inspections, oldest to newest
35. 35

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in February 2020 and February 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.

    2022232424252626F758 across all 8 inspections, oldest to newest
36. 36

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in February 2020 and February 2024. This citation covers whether residents are free from significant medication errors. 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.

    2022232424252626F760 across all 8 inspections, oldest to newest
37. 37

    Citation F809, Cited in Two Inspections

    Inspectors cited F809 in February 2024 and August 2025. The agency describes it this way: Ensure 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. 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.

    2022232424252626F809 across all 8 inspections, oldest to newest
38. 38

    Citation F838, Cited in Two Inspections

    Inspectors cited F838 in August 2025 and March 2026. The agency describes it this way: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. 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.

    2022232424252626F838 across all 8 inspections, oldest to newest
39. 39

    Citation F840, Cited in Two Inspections

    Inspectors cited F840 in June 2022 and August 2025. The agency describes it this way: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. 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.

    2022232424252626F840 across all 8 inspections, oldest to newest
40. 40

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in February 2020 and August 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.

    2022232424252626F842 across all 8 inspections, oldest to newest
41. 41

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in November 2023 and August 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2022232424252626F880 across all 8 inspections, oldest to newest
42. 42

    Citation F943, Cited in Two Inspections

    Inspectors cited F943 in February 2024 and August 2025. The agency describes it this way: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. 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.

    2022232424252626F943 across all 8 inspections, oldest to newest
43. 43

    Provide training in compliance and ethics, Cited in Two Inspections

    Inspectors cited F946 in February 2024 and August 2025. The agency describes it this way: Provide training in compliance and ethics. 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.

    2022232424252626F946 across all 8 inspections, oldest to newest
44. 44

    Citation F947, Cited in Two Inspections

    Inspectors cited F947 in February 2024 and August 2025. The agency describes it this way: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. 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.

    2022232424252626F947 across all 8 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 quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in six inspections, most seriously at level E.

2. 02

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

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

3. 03

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

   Protection From Abuse and Neglect: cited in five inspections, most seriously at level J.

4. 04

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

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

5. 05

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

   Care Plan Timing and Review: cited in four inspections, most seriously at level E.

6. 06

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

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

7. 07

   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 four inspections, most seriously at level E.

8. 08

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

   Accident Hazards and Supervision: cited in four inspections, most seriously at level J.

9. 09

   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 E.

10. 10

    What changed after F607 was cited, and how do you check it now?

    Citation F607: cited in three inspections, most seriously at level E.

11. 11

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

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

12. 12

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

    Continence and Catheter Care: cited in three inspections, most seriously at level E.

13. 13

    What changed after F730 was cited, and how do you check it now?

    Citation F730: cited in three inspections, most seriously at level E.

14. 14

    What changed after F745 was cited, and how do you check it now?

    Citation F745: cited in three inspections, most seriously at level D.

15. 15

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

    Food Quality and Temperature: cited in three inspections, most seriously at level E.

16. 16

    What changed after F941 was cited, and how do you check it now?

    Citation F941: cited in three inspections, most seriously at level D.

17. 17

    What changed after F942 was cited, and how do you check it now?

    Citation F942: cited in three inspections, most seriously at level D.

18. 18

    What changed after F944 was cited, and how do you check it now?

    Citation F944: cited in three inspections, most seriously at level D.

19. 19

    What changed after F949 was cited, and how do you check it now?

    Citation F949: cited in three inspections, most seriously at level D.

20. 20

    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.

21. 21

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

    Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

22. 22

    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 E.

23. 23

    What changed after F622 was cited, and how do you check it now?

    Citation F622: cited in two inspections, most seriously at level E.

24. 24

    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.

25. 25

    Was the required pre-admission screening done for every resident, and how is it tracked?

    Pre-Admission Screening: cited in two inspections, most seriously at level D.

26. 26

    What changed after F679 was cited, and how do you check it now?

    Provide activities to meet all resident's needs: cited in two inspections, most seriously at level E.

27. 27

    What changed after F680 was cited, and how do you check it now?

    Citation F680: cited in two inspections, most seriously at level F.

28. 28

    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 E.

29. 29

    What changed after F687 was cited, and how do you check it now?

    Provide appropriate foot care: cited in two inspections, most seriously at level D.

30. 30

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

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

31. 31

    What changed after F697 was cited, and how do you check it now?

    Citation F697: cited in two inspections, most seriously at level E.

32. 32

    What changed after F700 was cited, and how do you check it now?

    Citation F700: cited in two inspections, most seriously at level D.

33. 33

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

    Nursing Staff Levels: cited in two inspections, most seriously at level E.

34. 34

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level E.

35. 35

    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.

36. 36

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

    Significant Medication Errors: cited in two inspections, most seriously at level E.

37. 37

    What changed after F809 was cited, and how do you check it now?

    Citation F809: cited in two inspections, most seriously at level E.

38. 38

    What changed after F838 was cited, and how do you check it now?

    Citation F838: cited in two inspections, most seriously at level F.

39. 39

    What changed after F840 was cited, and how do you check it now?

    Citation F840: cited in two inspections, most seriously at level F.

40. 40

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

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

41. 41

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

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

42. 42

    What changed after F943 was cited, and how do you check it now?

    Citation F943: cited in two inspections, most seriously at level E.

43. 43

    What changed after F946 was cited, and how do you check it now?

    Provide training in compliance and ethics: cited in two inspections, most seriously at level D.

44. 44

    What changed after F947 was cited, and how do you check it now?

    Citation F947: cited in two inspections, most seriously at level E.

45. 45

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

    A $36,491 civil money penalty was imposed March 18, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

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

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

  Virginia state survey agency

  Inspection Feb 6, 2020 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Jun 7, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Nov 20, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Feb 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)

  Virginia state survey agency

  Inspection Apr 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)

  Virginia state survey agency

  Inspection Aug 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Mar 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)

  Virginia state survey agency

  Inspection Jul 2, 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 · 495362

  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.