The Vardell Report.Birchwood Park Rehabilitation

Across 6 inspections from March 2020 to April 2025, state surveyors documented 114 findings at Birchwood Park Rehabilitation; 114 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

6

2020–2025, complaint and standard

Findings

114

Deficiencies cited by state inspectors

Corrected

114

Of 114 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

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

1. Apr 42025

   Complaint investigation

   6 findings

   • 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, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected May 14, 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 May 14, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 14, 2025

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

2. Dec 192024

   Standard health inspection

   53 findings

   The same visit included a complaint investigation.

   • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level GActual harmCorrected Feb 15, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Feb 15, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Feb 15, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Feb 15, 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 FNo actual harm, potential for moreCorrected May 14, 2025
   • F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Feb 15, 2025
   • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Feb 15, 2025
   • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level FNo actual harm, potential for moreCorrected Feb 15, 2025
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Feb 15, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected May 14, 2025
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel ENo actual harm, potential for moreCorrected Feb 15, 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 May 14, 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 May 14, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected May 14, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected May 14, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 14, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F946Provide training in compliance and ethics.Level ENo actual harm, potential for moreCorrected Feb 15, 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 ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected Feb 15, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F560Protect a residents' right to refuse some types of non-requested transfers within the nursing home.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Feb 15, 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 May 14, 2025
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F586Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.Level DNo actual harm, potential for moreCorrected Feb 15, 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 May 14, 2025
   • 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 Feb 15, 2025
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 15, 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 DNo actual harm, potential for moreCorrected Feb 15, 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 May 14, 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 Feb 15, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • 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 Feb 15, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected May 14, 2025
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected May 14, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 15, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 14, 2025
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Feb 15, 2025

   Enforcement Action

   Civil money penalty, $131,178 imposed December 19, 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 December 19, 2024, the nearest before the penalty date.

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

3. Apr 152024

   Complaint investigation

   2 findings

   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected May 30, 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 2, 2024

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

4. Nov 32023

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Nov 28, 2023

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

5. Sep 302021

   Standard health inspection

   28 findings

   • F880Provide and implement an infection prevention and control program.Level LImmediate jeopardyCorrected Nov 5, 2021
   • F886Perform COVID19 testing on residents and staff.Level LImmediate jeopardyCorrected Nov 5, 2021
   • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 5, 2021
   • 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 5, 2021
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Nov 5, 2021
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 Nov 5, 2021
   • 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 Nov 5, 2021
   • 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 5, 2021
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 Nov 5, 2021
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Nov 5, 2021
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Nov 5, 2021
   • F885Report COVID19 data to residents and families.Level ENo actual harm, potential for moreCorrected Nov 5, 2021
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 5, 2021
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 5, 2021
   • 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 Nov 5, 2021
   • F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Nov 5, 2021
   • 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 5, 2021

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

6. Mar 52020

   Standard health inspection

   24 findings

   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Apr 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 ENo actual harm, potential for moreCorrected Apr 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 ENo actual harm, potential for moreCorrected Apr 10, 2020
   • 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 10, 2020
   • 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 10, 2020
   • 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 Apr 10, 2020
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Apr 10, 2020
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Apr 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 Apr 10, 2020
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Apr 10, 2020
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • 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 10, 2020
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 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 DNo actual harm, potential for moreCorrected Apr 10, 2020
   • 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 Apr 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 Apr 10, 2020
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Apr 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 Apr 10, 2020
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 10, 2020
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Apr 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

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in March 2020, September 2021 and December 2024. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   202123242425F584 across all 6 inspections, oldest to newest
2. 2

   Citation F607, Cited in Three Inspections

   Inspectors cited F607 in March 2020, December 2024 and April 2025. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.

   202123242425F607 across all 6 inspections, oldest to newest
3. 3

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in March 2020, December 2024 and April 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.

   202123242425F609 across all 6 inspections, oldest to newest
4. 4

   Investigating Alleged Violations, Cited in Three Inspections

   Inspectors cited F610 in March 2020, December 2024 and April 2025. 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.

   202123242425F610 across all 6 inspections, oldest to newest
5. 5

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in March 2020, September 2021 and December 2024. 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.

   202123242425F657 across all 6 inspections, oldest to newest
6. 6

   Medical Records, Cited in Three Inspections

   Inspectors cited F842 in March 2020, September 2021 and December 2024. 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.

   202123242425F842 across all 6 inspections, oldest to newest
7. 7

   Citation F883, Cited in Three Inspections

   Inspectors cited F883 in March 2020, September 2021 and December 2024. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

   202123242425F883 across all 6 inspections, oldest to newest
8. 8

   Dignity and Resident Rights, Cited in Two Inspections

   Inspectors cited F550 in December 2024 and April 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202123242425F550 across all 6 inspections, oldest to newest
9. 9

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in September 2021 and December 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202123242425F580 across all 6 inspections, oldest to newest
10. 10

    Citation F582, Cited in Two Inspections

    Inspectors cited F582 in March 2020 and September 2021. The agency describes it this way: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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.

    202123242425F582 across all 6 inspections, oldest to newest
11. 11

    Citation F583, Cited in Two Inspections

    Inspectors cited F583 in September 2021 and December 2024. The agency describes it this way: Keep residents' personal and medical records private and 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.

    202123242425F583 across all 6 inspections, oldest to newest
12. 12

    Citation F622, Cited in Two Inspections

    Inspectors cited F622 in March 2020 and September 2021. 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.

    202123242425F622 across all 6 inspections, oldest to newest
13. 13

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in September 2021 and December 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.

    202123242425F623 across all 6 inspections, oldest to newest
14. 14

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in March 2020 and September 2021. The agency describes it this way: Notify 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. 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.

    202123242425F625 across all 6 inspections, oldest to newest
15. 15

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in March 2020 and December 2024. This citation covers whether each resident’s assessment correctly records their condition. 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.

    202123242425F641 across all 6 inspections, oldest to newest
16. 16

    Pre-Admission Screening, Cited in Two Inspections

    Inspectors cited F645 in September 2021 and December 2024. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). 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.

    202123242425F645 across all 6 inspections, oldest to newest
17. 17

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in March 2020 and December 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.

    202123242425F656 across all 6 inspections, oldest to newest
18. 18

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in December 2024 and April 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.

    202123242425F677 across all 6 inspections, oldest to newest
19. 19

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in September 2021 and December 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F684 across all 6 inspections, oldest to newest
20. 20

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in November 2023 and December 2024. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F686 across all 6 inspections, oldest to newest
21. 21

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in March 2020 and December 2024. 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F689 across all 6 inspections, oldest to newest
22. 22

    Dialysis Care, Cited in Two Inspections

    Inspectors cited F698 in December 2024 and April 2025. This citation covers care for residents who need dialysis. 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.

    202123242425F698 across all 6 inspections, oldest to newest
23. 23

    Citation F727, Cited in Two Inspections

    Inspectors cited F727 in March 2020 and September 2021. The agency describes it this way: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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.

    202123242425F727 across all 6 inspections, oldest to newest
24. 24

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in March 2020 and December 2024. 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.

    202123242425F755 across all 6 inspections, oldest to newest
25. 25

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in March 2020 and December 2024. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 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.

    202123242425F756 across all 6 inspections, oldest to newest
26. 26

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in March 2020 and December 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F761 across all 6 inspections, oldest to newest
27. 27

    Citation F840, Cited in Two Inspections

    Inspectors cited F840 in September 2021 and December 2024. 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.

    202123242425F840 across all 6 inspections, oldest to newest
28. 28

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in September 2021 and December 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level L (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F880 across all 6 inspections, oldest to newest
29. 29

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in September 2021 and December 2024. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F921 across all 6 inspections, oldest to newest
30. 30

    Citation F925, Cited in Two Inspections

    Inspectors cited F925 in March 2020 and September 2021. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    202123242425F925 across all 6 inspections, oldest to newest

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

1. 01

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

   A Clean, Homelike Setting: cited in three inspections, most seriously at level F.

2. 02

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

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

3. 03

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

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

4. 04

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

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

5. 05

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

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

6. 06

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

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

7. 07

   What changed after F883 was cited, and how do you check it now?

   Citation F883: cited in three inspections, most seriously at level E.

8. 08

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in two inspections, most seriously at level D.

9. 09

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

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

10. 10

    What changed after F582 was cited, and how do you check it now?

    Citation F582: cited in two inspections, most seriously at level D.

11. 11

    What changed after F583 was cited, and how do you check it now?

    Citation F583: cited in two inspections, most seriously at level D.

12. 12

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

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

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

    What changed after F625 was cited, and how do you check it now?

    Citation F625: cited in two inspections, most seriously at level E.

15. 15

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

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

16. 16

    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 E.

17. 17

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

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

18. 18

    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.

19. 19

    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 G.

20. 20

    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 G.

21. 21

    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 two inspections, most seriously at level G.

22. 22

    How is dialysis care coordinated, and who monitors residents before and after treatment?

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

23. 23

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

    Citation F727: cited in two inspections, most seriously at level E.

24. 24

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

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

25. 25

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level E.

26. 26

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

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

27. 27

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

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

28. 28

    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 L.

29. 29

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

    Citation F921: cited in two inspections, most seriously at level E.

30. 30

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

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

31. 31

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

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

32. 32

    What led to the 2024 fine, and has it been paid?

    A $131,178 civil money penalty was imposed December 19, 2024. CMS publishes the fine, not whether it has been paid.

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

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

  Virginia state survey agency

  Inspection Mar 5, 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 Sep 30, 2021 · 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 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Apr 15, 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 Dec 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)

  Virginia state survey agency

  Inspection Apr 4, 2025 · 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 · 495150

  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.