The Vardell Report.Grand Avenue Rest Home

Across 11 inspections from September 2023 to July 2026, state surveyors documented 48 findings at Grand Avenue Rest Home; 45 have a recorded correction and 3 await one; CMS lists no enforcement action in the window.

Inspections

11

2023–2026, complaint and standard

Findings

48

Deficiencies cited by state inspectors

Corrected

45

Of 48 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

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

   • 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 7, 2026

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

2. Nov 262025

   Complaint investigation

   1 finding

   • 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 Dec 5, 2025

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

3. Sep 112025

   Standard health inspection

   8 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 31, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Oct 31, 2025
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmDeficient, Provider has no plan of correction

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

4. Jan 212025

   Complaint investigation

   2 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level FNo actual harm, potential for moreCorrected Feb 21, 2025
   • 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 21, 2025

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

5. Aug 282024

   Standard health inspection

   13 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 Oct 11, 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 Oct 11, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 11, 2024
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 11, 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 ENo actual harm, potential for moreCorrected Oct 11, 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 Oct 11, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Oct 11, 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 Oct 11, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 11, 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 Oct 11, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Oct 11, 2024

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

6. Jul 192024

   Complaint investigation

   1 finding

   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 31, 2024

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

7. Apr 152024

   Complaint investigation

   2 findings

   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level ENo actual harm, potential for moreCorrected May 4, 2024
   • F570Assure the security of all personal funds of residents deposited with the facility.Level ENo actual harm, potential for moreCorrected Apr 17, 2024

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

8. Apr 12024

   Complaint investigation

   1 finding

   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 27, 2024

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

9. Feb 202024

   Complaint investigation

   2 findings

   • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Mar 18, 2024
   • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Mar 18, 2024

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

10. Oct 262023

    Complaint investigation

    3 findings

    • 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 8, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 8, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 8, 2023

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

11. Sep 12023

    Standard health inspection

    14 findings

    • F570Assure the security of all personal funds of residents deposited with the facility.Level FNo actual harm, potential for moreCorrected Oct 31, 2023
    • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreWaiver has been granted
    • 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 31, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 31, 2023
    • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 31, 2023
    • 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 ENo actual harm, potential for moreCorrected Oct 31, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Oct 31, 2023
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Oct 31, 2023
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Oct 31, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Oct 31, 2023
    • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Oct 31, 2023
    • F583Keep residents' personal and medical records private and confidential.Level CPotential for minimal harmCorrected Oct 31, 2023
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level CPotential for minimal harmCorrected Oct 31, 2023
    • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmWaiver has been granted

    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

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in September 2023, August 2024 and September 2025. 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.

   2323242424242425252526F880 across all 11 inspections, oldest to newest
2. 2

   Citation F568, Cited in Two Inspections

   Inspectors cited F568 in February 2024 and April 2024. The agency describes it this way: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. 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.

   2323242424242425252526F568 across all 11 inspections, oldest to newest
3. 3

   Citation F570, Cited in Two Inspections

   Inspectors cited F570 in September 2023 and April 2024. The agency describes it this way: Assure the security of all personal funds of residents deposited with the facility. 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.

   2323242424242425252526F570 across all 11 inspections, oldest to newest
4. 4

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in August 2024 and July 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.

   2323242424242425252526F580 across all 11 inspections, oldest to newest
5. 5

   Citation F583, Cited in Two Inspections

   Inspectors cited F583 in September 2023 and August 2024. The agency describes it this way: Keep residents' personal and medical records private and confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242425252526F583 across all 11 inspections, oldest to newest
6. 6

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in October 2023 and August 2024. 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.

   2323242424242425252526F609 across all 11 inspections, oldest to newest
7. 7

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in January 2025 and September 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2323242424242425252526F657 across all 11 inspections, oldest to newest
8. 8

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in October 2023 and August 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.

   2323242424242425252526F684 across all 11 inspections, oldest to newest
9. 9

   Psychotropic Medications, Cited in Two Inspections

   Inspectors cited F758 in September 2023 and August 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. 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.

   2323242424242425252526F758 across all 11 inspections, oldest to newest
10. 10

    Antibiotic Use, Cited in Two Inspections

    Inspectors cited F881 in September 2023 and August 2024. This citation covers the home’s program for monitoring antibiotic use. 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.

    2323242424242425252526F881 across all 11 inspections, oldest to newest
11. 11

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in September 2023 and September 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

    2323242424242425252526F883 across all 11 inspections, oldest to newest
12. 12

    Citation F727, No Recorded Correction

    F727 was cited in September 2023, August 2024 and January 2025. The agency describes it this way: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. The most serious was level F (no actual harm, potential for more). The September 2023 citation has no recorded correction date; its status reads “Waiver has been granted.” The record does not show whether the problem was fixed.

    2323242424242425252526F727 across all 11 inspections, oldest to newest
13. 13

    Citation F912, No Recorded Correction

    F912 was cited in September 2023, August 2024 and September 2025. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The most serious was level B (potential for minimal harm). The September 2025 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.

    2323242424242425252526F912 across all 11 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 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.

2. 02

   What changed after F568 was cited, and how do you check it now?

   Citation F568: cited in two inspections, most seriously at level E.

3. 03

   What changed after F570 was cited, and how do you check it now?

   Citation F570: cited in two inspections, most seriously at level F.

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 two inspections, most seriously at level D.

5. 05

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

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

6. 06

   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 D.

7. 07

   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 F.

8. 08

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

   Quality of Care: cited in two inspections, most seriously at level D.

9. 09

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

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

10. 10

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in two inspections, most seriously at level F.

11. 11

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

    Citation F883: cited in two inspections, most seriously at level D.

12. 12

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

    Citation F727: cited in three inspections, most seriously at level F. The September 1, 2023 citation has no recorded correction date.

13. 13

    What changed after F912 was cited, and how do you check it now?

    Citation F912: cited in three inspections, most seriously at level B. The September 11, 2025 citation has no recorded correction date.

14. 14

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

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

15. 15

    Has the home been fined or had payments denied before this record begins?

    CMS lists no fines or payment denials in this window. The record starts September 1, 2023; anything earlier is not in it.

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

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

  Minnesota state survey agency

  Inspection Sep 1, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Oct 26, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Feb 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)

  Minnesota state survey agency

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

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

  Minnesota state survey agency

  Inspection Apr 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Jul 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Aug 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Jan 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Sep 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)

  Minnesota state survey agency

  Inspection Nov 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

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

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 24E150

  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.