The Vardell Report.The Terrace at Crystal LLC

Across 24 inspections from October 2023 to June 2026, state surveyors documented 139 findings at The Terrace at Crystal LLC; 115 have a recorded correction and 24 await one; CMS lists 11 enforcement actions in the window.

Inspections

24

2023–2026, standard and complaint

Findings

139

Deficiencies cited by state inspectors

Corrected

115

Of 139 findings, with a recorded correction date

Penalties

11

7 fines; payment not published, 4 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. Jun 52026

   Standard health inspection

   24 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level JImmediate jeopardyDeficient, Provider has no plan of correction
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmDeficient, Provider has no plan of correction
   • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F917Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F732Post nurse staffing information every day.Level CPotential for minimal harmDeficient, Provider has no plan of correction

   Enforcement Action

   Denial of payment imposed June 5, 2026. Status: Closed, July 16, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 5, 2026, the nearest before the penalty date.

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

2. Apr 162026

   Complaint investigation

   3 findings

   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected May 6, 2026
   • 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 May 6, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected May 6, 2026

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

3. Mar 192026

   Complaint investigation

   1 finding

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 9, 2026

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

4. Mar 52026

   Complaint investigation

   2 findings

   • 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 31, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 31, 2026

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

5. Jan 302026

   Complaint investigation

   1 finding

   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 13, 2026

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

6. Jan 212026

   Complaint investigation

   1 finding

   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Feb 13, 2026

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

7. Dec 82025

   Standard health inspection

   26 findings

   The same visit included a complaint investigation.

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Jan 22, 2026
   • F880Provide and implement an infection prevention and control program.Level KImmediate jeopardyCorrected Feb 20, 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 JImmediate jeopardyCorrected Jan 22, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level FNo actual harm, potential for moreCorrected Jan 22, 2026
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level FNo actual harm, potential for moreCorrected Jan 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 FNo actual harm, potential for moreCorrected Jan 22, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Jan 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 Jan 22, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level FNo actual harm, potential for moreCorrected Jan 22, 2026
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Feb 20, 2026
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level FNo actual harm, potential for moreCorrected Jan 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 Jan 22, 2026
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Jan 22, 2026
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Jan 22, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jan 22, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jan 22, 2026
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jan 22, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jan 22, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 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 Jan 22, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 22, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 20, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 20, 2026
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Feb 20, 2026
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Jan 22, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jan 22, 2026

   Enforcement Action

   Denial of payment imposed December 8, 2025. Status: Closed, February 20, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 8, 2025, the nearest before the penalty date.

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

8. Jul 22025

   Standard health inspection

   33 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Aug 26, 2025
   • 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 26, 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 Aug 26, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Aug 26, 2025
   • 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 Aug 26, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Aug 26, 2025
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Sep 11, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • 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 26, 2025
   • 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 26, 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 Aug 26, 2025
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 26, 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 Aug 26, 2025
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • 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 Aug 26, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Aug 26, 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 Aug 26, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 26, 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 Aug 26, 2025
   • 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 Aug 26, 2025
   • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Aug 26, 2025

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

9. Jun 272025

   Complaint investigation

   1 finding

   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 30, 2025

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

10. May 212025

    Complaint investigation

    2 findings

    • 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 Jun 24, 2025
    • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jun 24, 2025

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

11. Mar 272025

    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 ENo actual harm, potential for moreCorrected Apr 21, 2025

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

12. Mar 102025

    Complaint investigation

    1 finding

    • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Mar 27, 2025

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

13. Feb 132025

    Complaint investigation

    3 findings

    • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Mar 31, 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 Mar 31, 2025
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Mar 31, 2025

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

14. Jan 172025

    Complaint investigation

    6 findings

    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Feb 28, 2025
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
    • 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 Feb 28, 2025
    • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level DNo actual harm, potential for moreCorrected Feb 28, 2025

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

15. Dec 242024

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 2, 2025

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

16. Dec 62024

    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 Jan 6, 2025

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

17. Aug 302024

    Complaint investigation

    7 findings

    • 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 4, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 4, 2024
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Oct 4, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 4, 2024
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Oct 4, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 4, 2024

    Enforcement Action

    Denial of payment imposed August 30, 2024. Status: Closed, October 29, 2024. CMS does not tie a penalty to a survey; listed with the complaint investigation of August 30, 2024, the nearest before the penalty date.

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

18. Aug 62024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Aug 22, 2024

    Enforcement Action

    Civil money penalty, $18,146 imposed August 6, 2024. 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 August 6, 2024, the nearest before the penalty date.

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

19. Apr 122024

    Complaint investigation

    3 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 17, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 17, 2024
    • 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 CPotential for minimal harmCorrected May 17, 2024

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

20. Apr 42024

    Complaint investigation

    2 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 May 31, 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 May 31, 2024

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

21. Mar 272024

    Complaint investigation

    9 findings

    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level FNo actual harm, potential for moreCorrected May 31, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected May 31, 2024
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 31, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected May 31, 2024
    • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected May 31, 2024
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 31, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 31, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 31, 2024
    • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Jun 19, 2024

    Enforcement Action

    Civil money penalty, $17,813 imposed March 27, 2024. 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 March 27, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 27, 2024. Status: Closed, June 19, 2024. CMS does not tie a penalty to a survey; listed with the complaint investigation of March 27, 2024, the nearest before the penalty date.

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

22. Dec 82023

    Complaint investigation

    2 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 14, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 14, 2023

    Enforcement Action

    Civil money penalty, $11,645 imposed December 11, 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 8, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $4,545 imposed January 2, 2024. 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 8, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $4,938 imposed January 8, 2024. 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 8, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $14,814 imposed January 22, 2024. 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 8, 2023, the nearest before the penalty date.

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

23. Nov 282023

    Complaint investigation

    3 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 Dec 15, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 15, 2023
    • F926Have policies on smoking.Level DNo actual harm, potential for moreCorrected Dec 15, 2023

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

24. Oct 312023

    Complaint investigation

    5 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Nov 30, 2023
    • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level ENo actual harm, potential for moreCorrected Nov 30, 2023
    • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Nov 30, 2023
    • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Nov 30, 2023
    • F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level DNo actual harm, potential for moreCorrected Nov 30, 2023

    Enforcement Action

    Civil money penalty, $8,469 imposed November 6, 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 October 31, 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

   Care Plans, Cited in Five Inspections

   Inspectors cited F656 in November 2023, December 2024, January 2025, July 2025 and December 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323242424242424242525252525252525262626262626F656 across all 24 inspections, oldest to newest
2. 2

   Food Quality and Temperature, Cited in Five Inspections

   Inspectors cited F804 in March 2024, January 2025, February 2025, July 2025 and December 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323242424242424242525252525252525262626262626F804 across all 24 inspections, oldest to newest
3. 3

   Nutrition and Hydration, Cited in Three Inspections

   Inspectors cited F692 in March 2024, January 2025 and July 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

   232323242424242424242525252525252525262626262626F692 across all 24 inspections, oldest to newest
4. 4

   Citation F697, Cited in Three Inspections

   Inspectors cited F697 in July 2025, December 2025 and January 2026. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323242424242424242525252525252525262626262626F697 across all 24 inspections, oldest to newest
5. 5

   Citation F576, Cited in Two Inspections

   Inspectors cited F576 in July 2025 and December 2025. The agency describes it this way: Ensure residents have reasonable access to and privacy in their use of communication methods. 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.

   232323242424242424242525252525252525262626262626F576 across all 24 inspections, oldest to newest
6. 6

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in December 2023 and April 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.

   232323242424242424242525252525252525262626262626F609 across all 24 inspections, oldest to newest
7. 7

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in December 2023 and April 2024. 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.

   232323242424242424242525252525252525262626262626F610 across all 24 inspections, oldest to newest
8. 8

   Pressure Injury Care, Cited in Two Inspections

   Inspectors cited F686 in August 2024 and July 2025. 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.

   232323242424242424242525252525252525262626262626F686 across all 24 inspections, oldest to newest
9. 9

   Respiratory Care, Cited in Two Inspections

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

   232323242424242424242525252525252525262626262626F695 across all 24 inspections, oldest to newest
10. 10

    Citation F726, Cited in Two Inspections

    Inspectors cited F726 in March 2024 and December 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. 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.

    232323242424242424242525252525252525262626262626F726 across all 24 inspections, oldest to newest
11. 11

    Citation F740, Cited in Two Inspections

    Inspectors cited F740 in October 2023 and December 2025. The agency describes it this way: Ensure each resident must receive and the facility must provide necessary behavioral health care and services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323242424242424242525252525252525262626262626F740 across all 24 inspections, oldest to newest
12. 12

    Pharmacy Services, Cited in Two Inspections

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

    232323242424242424242525252525252525262626262626F755 across all 24 inspections, oldest to newest
13. 13

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in July 2025 and December 2025. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. 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.

    232323242424242424242525252525252525262626262626F757 across all 24 inspections, oldest to newest
14. 14

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in February 2025 and July 2025. This citation covers whether residents are free from significant medication errors. 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.

    232323242424242424242525252525252525262626262626F760 across all 24 inspections, oldest to newest
15. 15

    Citation F806, Cited in Two Inspections

    Inspectors cited F806 in January 2025 and July 2025. 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.

    232323242424242424242525252525252525262626262626F806 across all 24 inspections, oldest to newest
16. 16

    Citation F808, Cited in Two Inspections

    Inspectors cited F808 in January 2025 and July 2025. The agency describes it this way: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. 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.

    232323242424242424242525252525252525262626262626F808 across all 24 inspections, oldest to newest
17. 17

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in January 2026 and March 2026. 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.

    232323242424242424242525252525252525262626262626F842 across all 24 inspections, oldest to newest
18. 18

    Citation F919, Cited in Two Inspections

    Inspectors cited F919 in March 2024 and December 2025. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. 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.

    232323242424242424242525252525252525262626262626F919 across all 24 inspections, oldest to newest
19. 19

    Dignity and Resident Rights, No Recorded Correction

    F550 was cited in March 2024, January 2025, July 2025, December 2025 and June 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F550 across all 24 inspections, oldest to newest
20. 20

    Needs and Preferences, No Recorded Correction

    F558 was cited in March 2024 and June 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. The most serious was level E (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F558 across all 24 inspections, oldest to newest
21. 21

    Citation F605, No Recorded Correction

    F605 was cited in July 2025 and June 2026. The agency describes it this way: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F605 across all 24 inspections, oldest to newest
22. 22

    Citation F627, No Recorded Correction

    F627 was cited in May 2025, April 2026 and June 2026. The agency describes it this way: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F627 across all 24 inspections, oldest to newest
23. 23

    Citation F628, No Recorded Correction

    F628 was cited in May 2025, December 2025, April 2026 and June 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F628 across all 24 inspections, oldest to newest
24. 24

    Care Plan Timing and Review, No Recorded Correction

    F657 was cited in July 2025, December 2025 and June 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F657 across all 24 inspections, oldest to newest
25. 25

    Citation F676, No Recorded Correction

    F676 was cited in July 2025 and June 2026. The agency describes it this way: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F676 across all 24 inspections, oldest to newest
26. 26

    Help With Daily Living, No Recorded Correction

    F677 was cited in November 2023, August 2024, December 2025 and June 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. The most serious was level E (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F677 across all 24 inspections, oldest to newest
27. 27

    Provide activities to meet all resident's needs, No Recorded Correction

    F679 was cited in July 2025 and June 2026. The agency describes it this way: Provide activities to meet all resident's needs. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F679 across all 24 inspections, oldest to newest
28. 28

    Citation F680, No Recorded Correction

    F680 was cited in June 2026. The agency describes it this way: Ensure the activities program is directed by a qualified professional. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F680 across all 24 inspections, oldest to newest
29. 29

    Quality of Care, No Recorded Correction

    F684 was cited in July 2025, December 2025 and June 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious was level G (actual harm). The June 2026 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.

    232323242424242424242525252525252525262626262626F684 across all 24 inspections, oldest to newest
30. 30

    Citation F685, No Recorded Correction

    F685 was cited in August 2024 and June 2026. The agency describes it this way: Assist a resident in gaining access to vision and hearing services. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F685 across all 24 inspections, oldest to newest
31. 31

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in October 2023, April 2024, April 2024, August 2024, August 2024, July 2025, December 2025, March 2026 and June 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level K (immediate jeopardy). The June 2026 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.

    232323242424242424242525252525252525262626262626F689 across all 24 inspections, oldest to newest
32. 32

    Continence and Catheter Care, No Recorded Correction

    F690 was cited in June 2026. This citation covers continence care, catheter care and preventing urinary tract infections. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F690 across all 24 inspections, oldest to newest
33. 33

    Citation F712, No Recorded Correction

    F712 was cited in June 2026. The agency describes it this way: Ensure that the resident and his/her doctor meet face-to-face at all required visits. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F712 across all 24 inspections, oldest to newest
34. 34

    Post nurse staffing information every day, No Recorded Correction

    F732 was cited in June 2026. The agency describes it this way: Post nurse staffing information every day. The most serious was level C (potential for minimal harm). The June 2026 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.

    232323242424242424242525252525252525262626262626F732 across all 24 inspections, oldest to newest
35. 35

    Citation F756, No Recorded Correction

    F756 was cited in June 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F756 across all 24 inspections, oldest to newest
36. 36

    Kitchen and Food Safety, No Recorded Correction

    F812 was cited in July 2025 and June 2026. This citation covers how food is stored, prepared and served. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F812 across all 24 inspections, oldest to newest
37. 37

    Infection Control, No Recorded Correction

    F880 was cited in August 2024, December 2024, July 2025, December 2025 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level K (immediate jeopardy). The June 2026 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.

    232323242424242424242525252525252525262626262626F880 across all 24 inspections, oldest to newest
38. 38

    Keep all essential equipment working safely, No Recorded Correction

    F908 was cited in June 2026. The agency describes it this way: Keep all essential equipment working safely. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F908 across all 24 inspections, oldest to newest
39. 39

    Citation F917, No Recorded Correction

    F917 was cited in June 2026. The agency describes it this way: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. The most serious was level D (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F917 across all 24 inspections, oldest to newest
40. 40

    Citation F921, No Recorded Correction

    F921 was cited in August 2024, July 2025, December 2025 and June 2026. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F921 across all 24 inspections, oldest to newest
41. 41

    Citation F944, No Recorded Correction

    F944 was cited in December 2025 and June 2026. The agency describes it this way: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F944 across all 24 inspections, oldest to newest
42. 42

    Provide training in compliance and ethics, No Recorded Correction

    F946 was cited in December 2025 and June 2026. The agency describes it this way: Provide training in compliance and ethics. The most serious was level F (no actual harm, potential for more). The June 2026 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.

    232323242424242424242525252525252525262626262626F946 across all 24 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 is a care plan written and reviewed here, and how do families take part in it?

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

2. 02

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

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

3. 03

   How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

   Nutrition and Hydration: cited in three inspections, most seriously at level D.

4. 04

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

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

5. 05

   What changed after F576 was cited, and how do you check it now?

   Citation F576: cited in two inspections, most seriously at level F.

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

   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.

8. 08

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

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

9. 09

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

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

10. 10

    What changed after F726 was cited, and how do you check it now?

    Citation F726: cited in two inspections, most seriously at level F.

11. 11

    What changed after F740 was cited, and how do you check it now?

    Citation F740: cited in two inspections, most seriously at level D.

12. 12

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

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

13. 13

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

    Citation F757: cited in two inspections, most seriously at level D.

14. 14

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

    Significant Medication Errors: cited in two inspections, most seriously at level G.

15. 15

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

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

16. 16

    What changed after F808 was cited, and how do you check it now?

    Citation F808: cited in two inspections, most seriously at level D.

17. 17

    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.

18. 18

    What changed after F919 was cited, and how do you check it now?

    Citation F919: cited in two inspections, most seriously at level F.

19. 19

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

    Dignity and Resident Rights: cited in five inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

20. 20

    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 E. The June 5, 2026 citation has no recorded correction date.

21. 21

    What changed after F605 was cited, and how do you check it now?

    Citation F605: cited in two inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

22. 22

    What changed after F627 was cited, and how do you check it now?

    Citation F627: cited in three inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

23. 23

    What changed after F628 was cited, and how do you check it now?

    Citation F628: cited in four inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

24. 24

    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 D. The June 5, 2026 citation has no recorded correction date.

25. 25

    What changed after F676 was cited, and how do you check it now?

    Citation F676: cited in two inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

26. 26

    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 four inspections, most seriously at level E. The June 5, 2026 citation has no recorded correction date.

27. 27

    What changed after F679 was cited, and how do you check it now?

    Provide activities to meet all resident's needs: cited in two inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

28. 28

    What changed after F680 was cited, and how do you check it now?

    Citation F680: cited in one inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

29. 29

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

    Quality of Care: cited in three inspections, most seriously at level G. The June 5, 2026 citation has no recorded correction date.

30. 30

    What changed after F685 was cited, and how do you check it now?

    Citation F685: cited in two inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

31. 31

    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 nine inspections, most seriously at level K. The June 5, 2026 citation has no recorded correction date.

32. 32

    How is continence care scheduled, and how do you prevent urinary infections?

    Continence and Catheter Care: cited in one inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

33. 33

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

    Citation F712: cited in one inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

34. 34

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

    Post nurse staffing information every day: cited in one inspections, most seriously at level C. The June 5, 2026 citation has no recorded correction date.

35. 35

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

    Citation F756: cited in one inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

36. 36

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

    Kitchen and Food Safety: cited in two inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

37. 37

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

    Infection Control: cited in five inspections, most seriously at level K. The June 5, 2026 citation has no recorded correction date.

38. 38

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

    Keep all essential equipment working safely: cited in one inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

39. 39

    What changed after F917 was cited, and how do you check it now?

    Citation F917: cited in one inspections, most seriously at level D. The June 5, 2026 citation has no recorded correction date.

40. 40

    What changed after F921 was cited, and how do you check it now?

    Citation F921: cited in four inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

41. 41

    What changed after F944 was cited, and how do you check it now?

    Citation F944: cited in two inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

42. 42

    What changed after F946 was cited, and how do you check it now?

    Provide training in compliance and ethics: cited in two inspections, most seriously at level F. The June 5, 2026 citation has no recorded correction date.

43. 43

    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 December 2025.

44. 44

    What led to the 2026 denial of payment, and what would you want a family to know about it?

    Denial of payment was imposed June 5, 2026; it ended July 16, 2026. The record holds 11 enforcement actions in the window.

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 Oct 31, 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 Nov 28, 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 Dec 8, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Mar 27, 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 4, 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 12, 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 6, 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 30, 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 Dec 6, 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 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)

  Minnesota state survey agency

  Inspection Jan 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Feb 13, 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 Mar 10, 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 Mar 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection May 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 Jun 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Jul 2, 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 Dec 8, 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 Jan 21, 2026 · 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 30, 2026 · 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 Mar 5, 2026 · 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 Mar 19, 2026 · 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 16, 2026 · 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 Jun 5, 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 · 245289

  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.