The Vardell Report.Nexus at Elmwood

Across 27 inspections from December 2023 to July 2026, state surveyors documented 109 findings at Nexus at Elmwood; 109 have a recorded correction; CMS lists 13 enforcement actions in the window.

Inspections

27

2023–2026, complaint and standard

Findings

109

Deficiencies cited by state inspectors

Corrected

109

Of 109 findings, with a recorded correction date

Penalties

13

10 fines; payment not published, 3 closed

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

1. Jul 92026

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jul 19, 2026

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

2. May 272026

   Complaint investigation

   6 findings

   • 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 May 28, 2026
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected May 28, 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 May 28, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 28, 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 May 28, 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 May 28, 2026

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

3. Mar 292026

   Standard health inspection

   30 findings

   The same visit included a complaint investigation.

   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level GActual harmCorrected Apr 22, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 22, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Apr 22, 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 Apr 22, 2026
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • 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 Apr 22, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • 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 FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Apr 22, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Apr 22, 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 ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Apr 22, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Apr 22, 2026
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Apr 22, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 22, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 22, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Apr 22, 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 Apr 22, 2026

   Enforcement Action

   Civil money penalty, $89,700 imposed March 29, 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 March 29, 2026, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed March 29, 2026. Status: Closed, April 22, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 29, 2026, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $152,090 imposed July 9, 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 March 29, 2026, the nearest before the penalty date.

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

4. Feb 92026

   Complaint investigation

   4 findings

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

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

5. Jan 112026

   Complaint investigation

   2 findings

   • 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 Jan 12, 2026
   • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Jan 12, 2026

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

6. Dec 242025

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Dec 25, 2025
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level JImmediate jeopardyCorrected Dec 18, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level GActual harmCorrected Dec 25, 2025

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

7. Dec 112025

   Complaint investigation

   2 findings

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 12, 2025
   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreCorrected Dec 12, 2025

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

8. Dec 12025

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Dec 25, 2025
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Dec 2, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Dec 2, 2025

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

9. Nov 182025

   Complaint investigation

   1 finding

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Nov 19, 2025

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

10. Sep 42025

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Sep 5, 2025

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

11. Jul 92025

    Complaint investigation

    1 finding

    • 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, 2025

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

12. Jun 112025

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jun 12, 2025

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

13. May 162025

    Complaint investigation

    1 finding

    • 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 23, 2025

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

14. Apr 252025

    Complaint investigation

    2 findings

    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 30, 2025

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

15. Feb 32025

    Standard health inspection

    9 findings

    The same visit included a complaint investigation.

    • F695Provide safe and appropriate respiratory care for a resident when needed.Level JImmediate jeopardyCorrected Feb 4, 2025
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level GActual harmCorrected Feb 4, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Feb 4, 2025
    • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level FNo actual harm, potential for moreCorrected Feb 4, 2025
    • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level FNo actual harm, potential for moreCorrected Feb 4, 2025
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 4, 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 Feb 4, 2025
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 4, 2025
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Feb 4, 2025

    Enforcement Action

    Civil money penalty, $48,344 imposed February 3, 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 February 3, 2025, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $14,505 imposed June 11, 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 February 3, 2025, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $22,697 imposed September 4, 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 February 3, 2025, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $56,278 imposed December 1, 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 February 3, 2025, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed December 1, 2025. Status: Closed, February 10, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 3, 2025, the nearest before the penalty date.

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

16. Jan 72025

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jan 8, 2025

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

17. Dec 242024

    Complaint investigation

    1 finding

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 25, 2024

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

18. Dec 162024

    Complaint investigation

    1 finding

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 17, 2024

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

19. Nov 222024

    Complaint investigation

    2 findings

    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 23, 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 Nov 23, 2024

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

20. Nov 172024

    Complaint investigation

    3 findings

    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Nov 18, 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 Nov 18, 2024
    • F774Help the resident with transportation to and from laboratory services outside of the facility.Level DNo actual harm, potential for moreCorrected Nov 18, 2024

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

21. Oct 212024

    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 Oct 22, 2024

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

22. Aug 142024

    Complaint investigation

    5 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Aug 15, 2024
    • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level ENo actual harm, potential for moreCorrected Aug 15, 2024
    • F836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.Level ENo actual harm, potential for moreCorrected Aug 15, 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 Aug 15, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 15, 2024

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

23. Mar 202024

    Complaint investigation

    3 findings

    • F695Provide safe and appropriate respiratory care for a resident when needed.Level JImmediate jeopardyCorrected Mar 21, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 21, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 21, 2024

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

24. Mar 142024

    Standard health inspection

    8 findings

    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level FNo actual harm, potential for moreCorrected Mar 15, 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 15, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 15, 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 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 DNo actual harm, potential for moreCorrected Mar 15, 2024

    Enforcement Action

    Civil money penalty, $12,519 imposed August 14, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 14, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $31,993 imposed December 16, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 14, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $12,425 imposed January 7, 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 March 14, 2024, the nearest before the penalty date.

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

25. Feb 212024

    Complaint investigation

    11 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Feb 22, 2024
    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level GActual harmCorrected Feb 22, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Mar 15, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 15, 2024
    • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level GActual harmCorrected Feb 22, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Feb 22, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 22, 2024
    • F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Feb 22, 2024

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

26. Jan 112024

    Complaint investigation

    4 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Feb 22, 2024
    • F610Respond appropriately to all alleged violations.Level GActual harmCorrected Jan 12, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 21, 2024
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level DNo actual harm, potential for moreCorrected Jan 12, 2024

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

27. Dec 122023

    Complaint investigation

    2 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Mar 15, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jan 12, 2024

    Enforcement Action

    Civil money penalty, $222,671 imposed December 12, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of December 12, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed December 12, 2023. Status: Closed, March 21, 2024. CMS does not tie a penalty to a survey; listed with the complaint investigation of December 12, 2023, the nearest before the penalty date.

    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

   Quality of Care, Cited in Seven Inspections

   Inspectors cited F684 in March 2024, August 2024, February 2025, June 2025, December 2025, December 2025 and March 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 J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242424242424242425252525252525252525252626262626F684 across all 27 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in February 2024, March 2024, January 2025, May 2025, September 2025 and February 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242424242424242425252525252525252525252626262626F689 across all 27 inspections, oldest to newest
3. 3

   Protection From Abuse and Neglect, Cited in Five Inspections

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

   232424242424242424242425252525252525252525252626262626F600 across all 27 inspections, oldest to newest
4. 4

   Professional Standards, Cited in Five Inspections

   Inspectors cited F658 in March 2024, November 2024, February 2025, February 2026 and March 2026. This citation covers whether the home’s services meet professional standards of quality. 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.

   232424242424242424242425252525252525252525252626262626F658 across all 27 inspections, oldest to newest
5. 5

   Pharmacy Services, Cited in Five Inspections

   Inspectors cited F755 in October 2024, November 2024, February 2025, March 2026 and May 2026. 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.

   232424242424242424242425252525252525252525252626262626F755 across all 27 inspections, oldest to newest
6. 6

   Reporting Suspected Abuse, Cited in Four Inspections

   Inspectors cited F609 in February 2024, December 2024, April 2025 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.

   232424242424242424242425252525252525252525252626262626F609 across all 27 inspections, oldest to newest
7. 7

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in December 2023, February 2024, March 2024 and March 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.

   232424242424242424242425252525252525252525252626262626F686 across all 27 inspections, oldest to newest
8. 8

   Respiratory Care, Cited in Four Inspections

   Inspectors cited F695 in January 2024, March 2024, February 2025 and March 2026. This citation covers oxygen, breathing treatments and other respiratory care. 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.

   232424242424242424242425252525252525252525252626262626F695 across all 27 inspections, oldest to newest
9. 9

   Nursing Staff Levels, Cited in Four Inspections

   Inspectors cited F725 in February 2024, November 2025, March 2026 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. 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.

   232424242424242424242425252525252525252525252626262626F725 across all 27 inspections, oldest to newest
10. 10

    Citation F607, Cited in Three Inspections

    Inspectors cited F607 in March 2024, April 2025 and March 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F607 across all 27 inspections, oldest to newest
11. 11

    Investigating Alleged Violations, Cited in Three Inspections

    Inspectors cited F610 in December 2023, January 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F610 across all 27 inspections, oldest to newest
12. 12

    Significant Medication Errors, Cited in Three Inspections

    Inspectors cited F760 in February 2025, March 2026 and May 2026. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F760 across all 27 inspections, oldest to newest
13. 13

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in February 2025, December 2025 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F880 across all 27 inspections, oldest to newest
14. 14

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in January 2026 and March 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.

    232424242424242424242425252525252525252525252626262626F550 across all 27 inspections, oldest to newest
15. 15

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in March 2024 and March 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F558 across all 27 inspections, oldest to newest
16. 16

    Citation F602, Cited in Two Inspections

    Inspectors cited F602 in February 2024 and December 2025. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. 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.

    232424242424242424242425252525252525252525252626262626F602 across all 27 inspections, oldest to newest
17. 17

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in March 2024 and July 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.

    232424242424242424242425252525252525252525252626262626F677 across all 27 inspections, oldest to newest
18. 18

    Citation F678, Cited in Two Inspections

    Inspectors cited F678 in August 2024 and March 2026. The agency describes it this way: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. 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.

    232424242424242424242425252525252525252525252626262626F678 across all 27 inspections, oldest to newest
19. 19

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in February 2025 and March 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242424242424242425252525252525252525252626262626F761 across all 27 inspections, oldest to newest
20. 20

    Citation F773, Cited in Two Inspections

    Inspectors cited F773 in February 2024 and December 2025. The agency describes it this way: Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. 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.

    232424242424242424242425252525252525252525252626262626F773 across all 27 inspections, oldest to newest
21. 21

    Citation F839, Cited in Two Inspections

    Inspectors cited F839 in February 2025 and March 2026. The agency describes it this way: Employ staff that are licensed, certified, or registered in accordance with state laws. 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.

    232424242424242424242425252525252525252525252626262626F839 across all 27 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 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 seven inspections, most seriously at level J.

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 G.

3. 03

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

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

4. 04

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

   Professional Standards: cited in five inspections, most seriously at level G.

5. 05

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

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

6. 06

   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.

7. 07

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

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

8. 08

   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 J.

9. 09

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

   Nursing Staff Levels: cited in four inspections, most seriously at level F.

10. 10

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

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

11. 11

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

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

12. 12

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

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

13. 13

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

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

14. 14

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

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

15. 15

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

    Needs and Preferences: cited in two inspections, most seriously at level D.

16. 16

    What changed after F602 was cited, and how do you check it now?

    Citation F602: cited in two inspections, most seriously at level G.

17. 17

    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.

18. 18

    What changed after F678 was cited, and how do you check it now?

    Citation F678: cited in two inspections, most seriously at level E.

19. 19

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

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

20. 20

    What changed after F773 was cited, and how do you check it now?

    Citation F773: cited in two inspections, most seriously at level J.

21. 21

    What changed after F839 was cited, and how do you check it now?

    Citation F839: cited in two inspections, most seriously at level F.

22. 22

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

    A $152,090 civil money penalty was imposed July 9, 2026. CMS publishes the fine, not whether it has been paid. The record holds 13 enforcement actions in the window.

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

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

  Illinois state survey agency

  Inspection Dec 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jan 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Feb 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Mar 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)

  Illinois state survey agency

  Inspection Mar 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Aug 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)

  Illinois state survey agency

  Inspection Oct 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Nov 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)

  Illinois state survey agency

  Inspection Nov 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 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)

  Illinois state survey agency

  Inspection Jan 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Feb 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Apr 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection May 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)

  Illinois state survey agency

  Inspection Jun 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jul 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Sep 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Nov 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 1, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Dec 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jan 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Feb 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Mar 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection May 27, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Illinois state survey agency

  Inspection Jul 9, 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 · 145419

  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.