The Vardell Report.Glenburnie Rehab & Nursing Center

Across 9 inspections from July 2021 to June 2026, state surveyors documented 130 findings at Glenburnie Rehab & Nursing Center; 130 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

9

2021–2026, complaint and standard

Findings

130

Deficiencies cited by state inspectors

Corrected

130

Of 130 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. Jun 252026

   Complaint investigation

   3 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 29, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jul 29, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 29, 2026

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

2. Oct 292025

   Complaint investigation

   14 findings

   • 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 Dec 1, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Dec 1, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jan 2, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 2, 2026
   • 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 Dec 1, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 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 DNo actual harm, potential for moreCorrected Jan 2, 2026
   • 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 Jan 2, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 2, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 1, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Dec 1, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 1, 2025
   • F713Provide or arrange emergency care by a doctor 24 hours a day.Level DNo actual harm, potential for moreCorrected Dec 1, 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 Jan 2, 2026

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

3. Apr 172025

   Complaint investigation

   5 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level LImmediate jeopardyCorrected May 6, 2025
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected May 6, 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 ENo actual harm, potential for moreCorrected May 6, 2025
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected May 6, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected May 6, 2025

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

4. Mar 272025

   Complaint investigation

   9 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 31, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected May 31, 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 31, 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 May 31, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 31, 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 DNo actual harm, potential for moreCorrected May 31, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 31, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 31, 2025
   • 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 May 31, 2025

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

5. Jan 162025

   Complaint investigation

   10 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 Mar 1, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • 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 31, 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 DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Mar 1, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 31, 2025

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

6. May 142024

   Complaint investigation

   3 findings

   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Jun 26, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Jun 26, 2024
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jun 26, 2024

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

7. Jan 252024

   Standard health inspection

   25 findings

   The same visit included a complaint investigation.

   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Mar 8, 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 ENo actual harm, potential for moreCorrected Mar 8, 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 Mar 8, 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 ENo actual harm, potential for moreCorrected Mar 8, 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 Mar 8, 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 Mar 8, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Mar 8, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Mar 8, 2024
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Mar 8, 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 ENo actual harm, potential for moreCorrected Mar 8, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • 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 8, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 8, 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 Mar 8, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Mar 8, 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 DNo actual harm, potential for moreCorrected Mar 8, 2024
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 8, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 8, 2024

   Enforcement Action

   Civil money penalty, $54,211 imposed January 16, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 25, 2024, the nearest before the penalty date.

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

8. Feb 82023

   Standard health inspection

   38 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 Mar 21, 2023
   • 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 Mar 21, 2023
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 Mar 21, 2023
   • 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 21, 2023
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 Mar 21, 2023
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 21, 2023
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 Mar 21, 2023
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • 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 Mar 21, 2023
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 21, 2023
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 21, 2023

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

9. Jul 292021

   Standard health inspection

   23 findings

   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level ENo actual harm, potential for moreCorrected Aug 20, 2021
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Aug 20, 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 Aug 20, 2021
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Aug 20, 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 Aug 20, 2021
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Aug 20, 2021
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Aug 20, 2021
   • 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 Aug 20, 2021
   • 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 Aug 20, 2021
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 20, 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 Aug 20, 2021
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 20, 2021
   • 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 Aug 20, 2021
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Aug 20, 2021
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 20, 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 DNo actual harm, potential for moreCorrected Aug 20, 2021
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 20, 2021
   • 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 Aug 20, 2021
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Aug 20, 2021
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Aug 20, 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 Aug 20, 2021
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 20, 2021
   • F814Dispose of garbage and refuse properly.Level CPotential for minimal harmCorrected Aug 20, 2021

   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

   Care Plan Timing and Review, Cited in Six Inspections

   Inspectors cited F657 in July 2021, February 2023, January 2024, January 2025, March 2025 and October 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.

   212324242525252526F657 across all 9 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in July 2021, February 2023, January 2024, January 2025, March 2025 and April 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level L (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212324242525252526F689 across all 9 inspections, oldest to newest
3. 3

   A Clean, Homelike Setting, Cited in Five Inspections

   Inspectors cited F584 in July 2021, February 2023, January 2024, March 2025 and October 2025. 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.

   212324242525252526F584 across all 9 inspections, oldest to newest
4. 4

   Care Plans, Cited in Five Inspections

   Inspectors cited F656 in July 2021, February 2023, January 2024, March 2025 and October 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.

   212324242525252526F656 across all 9 inspections, oldest to newest
5. 5

   Dignity and Resident Rights, Cited in Four Inspections

   Inspectors cited F550 in July 2021, February 2023, March 2025 and October 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.

   212324242525252526F550 across all 9 inspections, oldest to newest
6. 6

   Accurate Assessments, Cited in Four Inspections

   Inspectors cited F641 in July 2021, February 2023, January 2024 and June 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212324242525252526F641 across all 9 inspections, oldest to newest
7. 7

   The First 48 Hours, Cited in Four Inspections

   Inspectors cited F655 in July 2021, February 2023, January 2025 and October 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

   212324242525252526F655 across all 9 inspections, oldest to newest
8. 8

   Professional Standards, Cited in Four Inspections

   Inspectors cited F658 in July 2021, February 2023, January 2024 and March 2025. 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.

   212324242525252526F658 across all 9 inspections, oldest to newest
9. 9

   Respiratory Care, Cited in Four Inspections

   Inspectors cited F695 in July 2021, February 2023, January 2024 and October 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212324242525252526F695 across all 9 inspections, oldest to newest
10. 10

    Post nurse staffing information every day, Cited in Four Inspections

    Inspectors cited F732 in July 2021, February 2023, January 2024 and April 2025. The agency describes it this way: Post nurse staffing information every day. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F732 across all 9 inspections, oldest to newest
11. 11

    Medical Records, Cited in Four Inspections

    Inspectors cited F842 in July 2021, February 2023, January 2024 and October 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F842 across all 9 inspections, oldest to newest
12. 12

    Needs and Preferences, Cited in Three Inspections

    Inspectors cited F558 in July 2021, January 2024 and October 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F558 across all 9 inspections, oldest to newest
13. 13

    Telling Families About Changes, Cited in Three Inspections

    Inspectors cited F580 in February 2023, January 2024 and January 2025. 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.

    212324242525252526F580 across all 9 inspections, oldest to newest
14. 14

    Help With Daily Living, Cited in Three Inspections

    Inspectors cited F677 in February 2023, January 2024 and October 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.

    212324242525252526F677 across all 9 inspections, oldest to newest
15. 15

    Quality of Care, Cited in Three Inspections

    Inspectors cited F684 in February 2023, January 2025 and March 2025. 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.

    212324242525252526F684 across all 9 inspections, oldest to newest
16. 16

    Continence and Catheter Care, Cited in Three Inspections

    Inspectors cited F690 in July 2021, January 2024 and October 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F690 across all 9 inspections, oldest to newest
17. 17

    Dialysis Care, Cited in Three Inspections

    Inspectors cited F698 in July 2021, February 2023 and January 2024. 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.

    212324242525252526F698 across all 9 inspections, oldest to newest
18. 18

    Pharmacy Services, Cited in Three Inspections

    Inspectors cited F755 in July 2021, February 2023 and January 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F755 across all 9 inspections, oldest to newest
19. 19

    Citation F757, Cited in Three Inspections

    Inspectors cited F757 in July 2021, May 2024 and March 2025. 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.

    212324242525252526F757 across all 9 inspections, oldest to newest
20. 20

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in July 2021, January 2024 and June 2026. 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.

    212324242525252526F812 across all 9 inspections, oldest to newest
21. 21

    Citation F583, Cited in Two Inspections

    Inspectors cited F583 in February 2023 and June 2026. 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.

    212324242525252526F583 across all 9 inspections, oldest to newest
22. 22

    Citation F607, Cited in Two Inspections

    Inspectors cited F607 in January 2024 and January 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.

    212324242525252526F607 across all 9 inspections, oldest to newest
23. 23

    Citation F622, Cited in Two Inspections

    Inspectors cited F622 in July 2021 and February 2023. 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.

    212324242525252526F622 across all 9 inspections, oldest to newest
24. 24

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in July 2021 and February 2023. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F623 across all 9 inspections, oldest to newest
25. 25

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in July 2021 and February 2023. 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.

    212324242525252526F625 across all 9 inspections, oldest to newest
26. 26

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in February 2023 and October 2025. 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.

    212324242525252526F686 across all 9 inspections, oldest to newest
27. 27

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in February 2023 and October 2025. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. 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.

    212324242525252526F697 across all 9 inspections, oldest to newest
28. 28

    Citation F712, Cited in Two Inspections

    Inspectors cited F712 in February 2023 and April 2025. The agency describes it this way: Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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.

    212324242525252526F712 across all 9 inspections, oldest to newest
29. 29

    Citation F745, Cited in Two Inspections

    Inspectors cited F745 in January 2024 and January 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.

    212324242525252526F745 across all 9 inspections, oldest to newest
30. 30

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in July 2021 and January 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. 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.

    212324242525252526F758 across all 9 inspections, oldest to newest
31. 31

    Citation F840, Cited in Two Inspections

    Inspectors cited F840 in February 2023 and April 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212324242525252526F840 across all 9 inspections, oldest to newest
32. 32

    Infection Control, Cited in Two Inspections

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

    212324242525252526F880 across all 9 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 often are care plans revised, and who takes part in the review?

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

2. 02

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

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

3. 03

   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.

4. 04

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

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

5. 05

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

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

6. 06

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

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

7. 07

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

   The First 48 Hours: cited in four inspections, most seriously at level E.

8. 08

   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.

9. 09

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

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

10. 10

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in four inspections, most seriously at level C.

11. 11

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

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

12. 12

    How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

    Needs and Preferences: cited in three inspections, most seriously at level E.

13. 13

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

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

14. 14

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

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

15. 15

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in three inspections, most seriously at level E.

16. 16

    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.

17. 17

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

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

18. 18

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

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

19. 19

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

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

20. 20

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

    Kitchen and Food Safety: cited in three inspections, most seriously at level E.

21. 21

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

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

22. 22

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

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

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 E.

25. 25

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

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

26. 26

    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.

27. 27

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

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

28. 28

    What changed after F712 was cited, and how do you check it now?

    Citation F712: cited in two inspections, most seriously at level D.

29. 29

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

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

30. 30

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

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

31. 31

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

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

32. 32

    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 E.

33. 33

    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.

34. 34

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

    A $54,211 civil money penalty was imposed January 16, 2025. CMS publishes the fine, not whether it has been paid.

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

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

  Virginia state survey agency

  Inspection Jul 29, 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 Feb 8, 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 Jan 25, 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 May 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Jan 16, 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 27, 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 Apr 17, 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 Oct 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Virginia state survey agency

  Inspection Jun 25, 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 · 495391

  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.