The Vardell Report.Kings Daughters Community Health & Rehab

Across 8 inspections from June 2019 to May 2026, state surveyors documented 83 findings at Kings Daughters Community Health & Rehab; 77 have a recorded correction and 6 await one; CMS lists 1 enforcement action in the window.

Inspections

8

2019–2026, complaint and standard

Findings

83

Deficiencies cited by state inspectors

Corrected

77

Of 83 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. May 152026

   Complaint investigation

   17 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level KImmediate jeopardyCorrected Jun 23, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level KImmediate jeopardyCorrected Jun 23, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level HActual harmCorrected Jun 23, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 23, 2026
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level GActual harmCorrected Jun 23, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level FNo actual harm, potential for moreCorrected Jun 23, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 23, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 16, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 16, 2026
   • 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 Jun 23, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 16, 2026
   • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F917Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Level DNo actual harm, potential for moreCorrected Jun 23, 2026

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

2. Dec 172025

   Complaint investigation

   5 findings

   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Feb 9, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 9, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Feb 9, 2026
   • 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 Feb 9, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 9, 2026

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

3. Jul 242024

   Complaint investigation

   1 finding

   • 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 Aug 13, 2024

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

4. Apr 172024

   Complaint investigation

   31 findings

   • F610Respond appropriately to all alleged violations.Level LImmediate jeopardyCorrected Jul 15, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level KImmediate jeopardyCorrected Jul 15, 2024
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jul 15, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jul 15, 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 GActual harmCorrected Jul 15, 2024
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level GActual harmCorrected Jul 15, 2024
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level FNo actual harm, potential for moreCorrected Jul 15, 2024
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Jul 15, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • 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 Jul 15, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 15, 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 Jul 15, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • 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 Aug 13, 2024
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Jul 15, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 15, 2024

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

5. Nov 292023

   Complaint investigation

   6 findings

   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level FNo actual harm, potential for moreCorrected Jan 5, 2024
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level FNo actual harm, potential for moreCorrected Jan 5, 2024
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected Jan 5, 2024
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jan 5, 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 Jan 5, 2024
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jan 5, 2024

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

6. Feb 22023

   Standard health inspection

   8 findings

   • 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 moreDeficient, Provider has no plan of correction
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 8, 2023
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 8, 2023
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Enforcement Action

   Civil money penalty, $61,711 imposed May 15, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 2, 2023, the nearest before the penalty date.

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

7. Apr 152021

   Standard health inspection

   7 findings

   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected May 19, 2021
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 19, 2021

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

8. Jun 242019

   Standard health inspection

   8 findings

   • 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 KImmediate jeopardyCorrected Jul 22, 2019
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Jul 22, 2019
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Jul 22, 2019
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 22, 2019
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 22, 2019
   • 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 Jul 22, 2019
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jul 22, 2019
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 22, 2019

   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

   Accurate Assessments, Cited in Four Inspections

   Inspectors cited F641 in April 2021, February 2023, April 2024 and May 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.

   1921232324242526F641 across all 8 inspections, oldest to newest
2. 2

   Professional Standards, Cited in Four Inspections

   Inspectors cited F658 in April 2021, April 2024, December 2025 and May 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

   1921232324242526F658 across all 8 inspections, oldest to newest
3. 3

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in April 2021, April 2024, December 2025 and May 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.

   1921232324242526F684 across all 8 inspections, oldest to newest
4. 4

   Medical Records, Cited in Four Inspections

   Inspectors cited F842 in June 2019, February 2023, April 2024 and December 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921232324242526F842 across all 8 inspections, oldest to newest
5. 5

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in June 2019, April 2024 and May 2026. 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.

   1921232324242526F686 across all 8 inspections, oldest to newest
6. 6

   Pharmacy Services, Cited in Three Inspections

   Inspectors cited F755 in April 2024, July 2024 and May 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921232324242526F755 across all 8 inspections, oldest to newest
7. 7

   Administration, Cited in Three Inspections

   Inspectors cited F835 in June 2019, April 2024 and May 2026. This citation covers whether the home is run in a way that uses its resources effectively. 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.

   1921232324242526F835 across all 8 inspections, oldest to newest
8. 8

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in April 2024 and May 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921232324242526F600 across all 8 inspections, oldest to newest
9. 9

   Citation F607, Cited in Two Inspections

   Inspectors cited F607 in April 2024 and May 2026. 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.

   1921232324242526F607 across all 8 inspections, oldest to newest
10. 10

    Reporting Suspected Abuse, Cited in Two Inspections

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

    1921232324242526F609 across all 8 inspections, oldest to newest
11. 11

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in April 2024 and May 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. 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.

    1921232324242526F610 across all 8 inspections, oldest to newest
12. 12

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in April 2024 and May 2026. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1921232324242526F657 across all 8 inspections, oldest to newest
13. 13

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in April 2021 and April 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

    1921232324242526F677 across all 8 inspections, oldest to newest
14. 14

    Nursing Staff Levels, Cited in Two Inspections

    Inspectors cited F725 in April 2024 and May 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1921232324242526F725 across all 8 inspections, oldest to newest
15. 15

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in November 2023 and April 2024. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1921232324242526F804 across all 8 inspections, oldest to newest
16. 16

    Citation F809, Cited in Two Inspections

    Inspectors cited F809 in November 2023 and April 2024. The agency describes it this way: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1921232324242526F809 across all 8 inspections, oldest to newest
17. 17

    Citation F865, Cited in Two Inspections

    Inspectors cited F865 in June 2019 and April 2024. The agency describes it this way: Have a plan that describes the process for conducting QAPI and QAA activities. 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.

    1921232324242526F865 across all 8 inspections, oldest to newest
18. 18

    The First 48 Hours, No Recorded Correction

    F655 was cited in February 2023. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. The most serious was level D (no actual harm, potential for more). The February 2023 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    1921232324242526F655 across all 8 inspections, oldest to newest
19. 19

    Citation F756, No Recorded Correction

    F756 was cited in February 2023. 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. The most serious was level E (no actual harm, potential for more). The February 2023 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    1921232324242526F756 across all 8 inspections, oldest to newest
20. 20

    Medication Labeling and Storage, No Recorded Correction

    F761 was cited in June 2019, April 2021 and February 2023. This citation covers how drugs are labeled and kept locked, including controlled drugs. The most serious was level D (no actual harm, potential for more). The February 2023 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    1921232324242526F761 across all 8 inspections, oldest to newest
21. 21

    Citation F805, No Recorded Correction

    F805 was cited in February 2023. The agency describes it this way: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. The most serious was level D (no actual harm, potential for more). The February 2023 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    1921232324242526F805 across all 8 inspections, oldest to newest
22. 22

    Kitchen and Food Safety, No Recorded Correction

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

    1921232324242526F812 across all 8 inspections, oldest to newest
23. 23

    Infection Control, No Recorded Correction

    F880 was cited in April 2021, February 2023, December 2025 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level E (no actual harm, potential for more). The February 2023 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    1921232324242526F880 across all 8 inspections, oldest to newest

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

1. 01

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

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

2. 02

   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 D.

3. 03

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

   Quality of Care: cited in four inspections, most seriously at level F.

4. 04

   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 D.

5. 05

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

   Pressure Injury Care: cited in three inspections, most seriously at level G.

6. 06

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

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

7. 07

   How long have the administrator and the director of nursing been in their roles?

   Administration: cited in three inspections, most seriously at level G.

8. 08

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

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

9. 09

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

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

10. 10

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

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

11. 11

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

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

12. 12

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

    Care Plan Timing and Review: cited in two inspections, most seriously at level D.

13. 13

    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 D.

14. 14

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

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

15. 15

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

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

16. 16

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

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

17. 17

    What changed after F865 was cited, and how do you check it now?

    Citation F865: cited in two inspections, most seriously at level F.

18. 18

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

    The First 48 Hours: cited in one inspections, most seriously at level D. The February 2, 2023 citation has no recorded correction date.

19. 19

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

    Citation F756: cited in one inspections, most seriously at level E. The February 2, 2023 citation has no recorded correction date.

20. 20

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

    Medication Labeling and Storage: cited in three inspections, most seriously at level D. The February 2, 2023 citation has no recorded correction date.

21. 21

    What changed after F805 was cited, and how do you check it now?

    Citation F805: cited in one inspections, most seriously at level D. The February 2, 2023 citation has no recorded correction date.

22. 22

    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. The February 2, 2023 citation has no recorded correction date.

23. 23

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

    Infection Control: cited in four inspections, most seriously at level E. The February 2, 2023 citation has no recorded correction date.

24. 24

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

    A $61,711 civil money penalty was imposed May 15, 2026. 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 Jun 24, 2019 · 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, 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 2, 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 Nov 29, 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 17, 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 Jul 24, 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 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 May 15, 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 · 495344

  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.