The Vardell Report.Wonder City Rehabilitation and Nursing Center

Across 5 inspections from August 2018 to May 2026, state surveyors documented 93 findings at Wonder City Rehabilitation and Nursing Center; 93 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

5

2018–2026, complaint and standard

Findings

93

Deficiencies cited by state inspectors

Corrected

93

Of 93 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 72026

   Complaint investigation

   21 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Jun 21, 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 FNo actual harm, potential for moreCorrected Jun 21, 2026
   • 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 Jun 21, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Jun 21, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 4, 2026
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Jun 21, 2026
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Jun 21, 2026
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Jun 21, 2026
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Aug 4, 2026
   • 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 Jun 21, 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 ENo actual harm, potential for moreCorrected Jun 21, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 21, 2026
   • 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 ENo actual harm, potential for moreCorrected Jun 21, 2026
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Jun 21, 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 Jun 21, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jun 21, 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 21, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 21, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 21, 2026
   • 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 Jun 21, 2026
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jun 21, 2026

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

2. Nov 32023

   Complaint investigation

   15 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Jan 4, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 4, 2024
   • 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 Jan 4, 2024
   • 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 Jan 4, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jan 4, 2024
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jan 4, 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 Jan 4, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jan 4, 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 Jan 4, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 4, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 4, 2024
   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Jan 4, 2024
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jan 4, 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 Jan 4, 2024
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jan 4, 2024

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

3. Jul 142023

   Standard health inspection

   38 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Jan 4, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 4, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jan 4, 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 Oct 9, 2023
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level GActual harmCorrected Oct 9, 2023
   • 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 Aug 17, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Aug 17, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Oct 9, 2023
   • F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Level FNo actual harm, potential for moreCorrected Aug 17, 2023
   • 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 Jan 4, 2024
   • 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 Jan 4, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jan 4, 2024
   • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Aug 17, 2023
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jan 4, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • 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 Jan 4, 2024
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Aug 17, 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 Aug 17, 2023
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jan 4, 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 Jan 4, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 4, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 17, 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 Jan 4, 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 Aug 17, 2023
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jan 4, 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 Jan 4, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Oct 9, 2023
   • 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 Oct 9, 2023
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jan 4, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 17, 2023

   Enforcement Action

   Civil money penalty, $74,210 imposed May 7, 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 July 14, 2023, the nearest before the penalty date.

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

4. May 62021

   Standard health inspection

   11 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 31, 2021
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected May 31, 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 ENo actual harm, potential for moreCorrected May 31, 2021
   • 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 May 31, 2021
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected May 31, 2021
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected May 31, 2021
   • 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 31, 2021
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected May 31, 2021
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 31, 2021
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected May 31, 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 May 31, 2021

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

5. Aug 92018

   Standard health inspection

   8 findings

   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel ENo actual harm, potential for moreCorrected Sep 24, 2018
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Sep 24, 2018
   • 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 Sep 24, 2018
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Sep 24, 2018
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 24, 2018
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 24, 2018
   • 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 Sep 24, 2018
   • 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 Sep 24, 2018

   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

   Reporting Suspected Abuse, Cited in Four Inspections

   Inspectors cited F609 in August 2018, May 2021, July 2023 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F609 across all 5 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in May 2021, July 2023, November 2023 and May 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F684 across all 5 inspections, oldest to newest
3. 3

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in May 2021, July 2023, November 2023 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F689 across all 5 inspections, oldest to newest
4. 4

   Telling Families About Changes, Cited in Three Inspections

   Inspectors cited F580 in July 2023, November 2023 and May 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F580 across all 5 inspections, oldest to newest
5. 5

   Pre-Admission Screening, Cited in Three Inspections

   Inspectors cited F645 in August 2018, July 2023 and November 2023. 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.

   1821232326F645 across all 5 inspections, oldest to newest
6. 6

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in July 2023, November 2023 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F657 across all 5 inspections, oldest to newest
7. 7

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in August 2018, July 2023 and November 2023. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1821232326F686 across all 5 inspections, oldest to newest
8. 8

   Food Quality and Temperature, Cited in Three Inspections

   Inspectors cited F804 in May 2021, July 2023 and May 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

   1821232326F804 across all 5 inspections, oldest to newest
9. 9

   Citation F806, Cited in Three Inspections

   Inspectors cited F806 in July 2023, November 2023 and May 2026. The agency describes it this way: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. 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.

   1821232326F806 across all 5 inspections, oldest to newest
10. 10

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in May 2021, July 2023 and May 2026. This citation covers how food is stored, prepared and served. 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.

    1821232326F812 across all 5 inspections, oldest to newest
11. 11

    Keep all essential equipment working safely, Cited in Three Inspections

    Inspectors cited F908 in July 2023, November 2023 and May 2026. The agency describes it this way: Keep all essential equipment working safely. 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.

    1821232326F908 across all 5 inspections, oldest to newest
12. 12

    Citation F925, Cited in Three Inspections

    Inspectors cited F925 in July 2023, November 2023 and May 2026. 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.

    1821232326F925 across all 5 inspections, oldest to newest
13. 13

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in May 2021 and May 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1821232326F584 across all 5 inspections, oldest to newest
14. 14

    Citation F607, Cited in Two Inspections

    Inspectors cited F607 in August 2018 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.

    1821232326F607 across all 5 inspections, oldest to newest
15. 15

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in July 2023 and May 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1821232326F610 across all 5 inspections, oldest to newest
16. 16

    Notice Before Transfer or Discharge, Cited in Two Inspections

    Inspectors cited F623 in July 2023 and November 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.

    1821232326F623 across all 5 inspections, oldest to newest
17. 17

    Coordinating Mental Health Screening, Cited in Two Inspections

    Inspectors cited F644 in May 2021 and July 2023. This citation covers whether assessments are coordinated with the state’s pre-admission screening for mental illness and intellectual disability (PASARR), and referrals made. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1821232326F644 across all 5 inspections, oldest to newest
18. 18

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in July 2023 and November 2023. 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.

    1821232326F658 across all 5 inspections, oldest to newest
19. 19

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in July 2023 and November 2023. 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.

    1821232326F677 across all 5 inspections, oldest to newest
20. 20

    Citation F700, Cited in Two Inspections

    Inspectors cited F700 in July 2023 and November 2023. The agency describes it this way: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1821232326F700 across all 5 inspections, oldest to newest
21. 21

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in August 2018 and July 2023. 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.

    1821232326F758 across all 5 inspections, oldest to newest
22. 22

    Citation F802, Cited in Two Inspections

    Inspectors cited F802 in July 2023 and May 2026. The agency describes it this way: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition 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.

    1821232326F802 across all 5 inspections, oldest to newest
23. 23

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in July 2023 and November 2023. 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.

    1821232326F842 across all 5 inspections, oldest to newest
24. 24

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in July 2023 and November 2023. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. 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.

    1821232326F867 across all 5 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 are staff trained to report suspected abuse or neglect, and who reports it to the state?

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

2. 02

   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 G.

3. 03

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

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

4. 04

   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 D.

5. 05

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

   Pre-Admission Screening: cited in three inspections, most seriously at level E.

6. 06

   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.

7. 07

   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 J.

8. 08

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

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

9. 09

   What changed after F806 was cited, and how do you check it now?

   Citation F806: cited in three inspections, most seriously at level D.

10. 10

    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 F.

11. 11

    What changed after F908 was cited, and how do you check it now?

    Keep all essential equipment working safely: cited in three inspections, most seriously at level F.

12. 12

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

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

13. 13

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

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

14. 14

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

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

15. 15

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

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

16. 16

    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.

17. 17

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

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

18. 18

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

    Professional Standards: cited in two inspections, most seriously at level D.

19. 19

    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.

20. 20

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

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

21. 21

    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.

22. 22

    What changed after F802 was cited, and how do you check it now?

    Citation F802: cited in two inspections, most seriously at level F.

23. 23

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

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

24. 24

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

25. 25

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

    Insufficient nursing staff was cited in May 2026.

26. 26

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

    A $74,210 civil money penalty was imposed May 7, 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 Aug 9, 2018 · 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 6, 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 Jul 14, 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 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 May 7, 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 · 495123

  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.