The Vardell Report.The Villas at the Cedars

Across 15 inspections from July 2023 to September 2026, state surveyors documented 63 findings at The Villas at the Cedars; 49 have a recorded correction and 14 await one; CMS lists 1 enforcement action in the window.

Inspections

15

2023–2026, standard and complaint

Findings

63

Deficiencies cited by state inspectors

Corrected

49

Of 63 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

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

1. Sep 112026

   Standard health inspection

   14 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for 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
   • F554Allow residents to self-administer drugs if determined clinically appropriate.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
   • 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 DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • 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 moreDeficient, Provider has no plan of correction
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

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

2. Mar 32026

   Complaint investigation

   4 findings

   • 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 Apr 7, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 7, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 7, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 7, 2026

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

3. Jan 272026

   Complaint investigation

   2 findings

   • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Jan 20, 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 Feb 11, 2026

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

4. Dec 22025

   Complaint investigation

   3 findings

   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 22, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 22, 2025

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

5. Aug 52025

   Complaint investigation

   1 finding

   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Aug 26, 2025

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

6. Jul 152025

   Complaint investigation

   6 findings

   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level ENo actual harm, potential for moreCorrected Aug 26, 2025
   • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level ENo 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
   • 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
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Aug 26, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Aug 26, 2025

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

7. Jun 262025

   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 Jul 16, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 16, 2025

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

8. May 142025

   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 Jun 9, 2025

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

9. Apr 32025

   Complaint investigation

   2 findings

   • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected May 13, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 13, 2025

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

10. Dec 52024

    Complaint investigation

    1 finding

    • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Dec 18, 2024

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

11. Nov 72024

    Complaint investigation

    3 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Oct 31, 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 Dec 4, 2024
    • 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 4, 2024

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

12. Sep 192024

    Standard health inspection

    9 findings

    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 24, 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 Oct 24, 2024
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Oct 24, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 24, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Oct 24, 2024
    • 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 Oct 24, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 24, 2024
    • 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 Oct 24, 2024
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Oct 24, 2024

    Enforcement Action

    Civil money penalty, $22,205 imposed September 19, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 19, 2024, the nearest before the penalty date.

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

13. Aug 132024

    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 Aug 28, 2024

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

14. Nov 162023

    Complaint investigation

    1 finding

    • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Dec 12, 2023

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

15. Jul 142023

    Standard health inspection

    13 findings

    • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level ENo actual harm, potential for moreCorrected Sep 12, 2023
    • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Sep 12, 2023
    • 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 Sep 12, 2023
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Sep 12, 2023
    • 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 Sep 12, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Sep 12, 2023

    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

   Telling Families About Changes, Cited in Three Inspections

   Inspectors cited F580 in July 2023, May 2025 and March 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.

   232324242424252525252525262626F580 across all 15 inspections, oldest to newest
2. 2

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in September 2024, November 2024 and July 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.

   232324242424252525252525262626F656 across all 15 inspections, oldest to newest
3. 3

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in September 2024, April 2025 and December 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.

   232324242424252525252525262626F880 across all 15 inspections, oldest to newest
4. 4

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in November 2024 and June 2025. 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.

   232324242424252525252525262626F609 across all 15 inspections, oldest to newest
5. 5

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in July 2023 and June 2025. 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.

   232324242424252525252525262626F610 across all 15 inspections, oldest to newest
6. 6

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in July 2023 and January 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424252525252525262626F657 across all 15 inspections, oldest to newest
7. 7

   Provide activities to meet all resident's needs, Cited in Two Inspections

   Inspectors cited F679 in July 2023 and December 2025. The agency describes it this way: Provide activities to meet all resident's needs. 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.

   232324242424252525252525262626F679 across all 15 inspections, oldest to newest
8. 8

   Nutrition and Hydration, Cited in Two Inspections

   Inspectors cited F692 in July 2023 and August 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

   232324242424252525252525262626F692 across all 15 inspections, oldest to newest
9. 9

   Citation F700, Cited in Two Inspections

   Inspectors cited F700 in July 2023 and July 2025. The agency describes it this way: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424252525252525262626F700 across all 15 inspections, oldest to newest
10. 10

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in January 2026 and March 2026. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424252525252525262626F760 across all 15 inspections, oldest to newest
11. 11

    Dignity and Resident Rights, No Recorded Correction

    F550 was cited in September 2024 and September 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F550 across all 15 inspections, oldest to newest
12. 12

    Residents Taking Their Own Medication, No Recorded Correction

    F554 was cited in September 2024 and September 2026. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F554 across all 15 inspections, oldest to newest
13. 13

    Needs and Preferences, No Recorded Correction

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

    232324242424252525252525262626F558 across all 15 inspections, oldest to newest
14. 14

    Citation F565, No Recorded Correction

    F565 was cited in July 2023 and September 2026. The agency describes it this way: Honor the resident's right to organize and participate in resident/family groups in the facility. The most serious was level E (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F565 across all 15 inspections, oldest to newest
15. 15

    A Clean, Homelike Setting, No Recorded Correction

    F584 was cited in September 2024 and September 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F584 across all 15 inspections, oldest to newest
16. 16

    Grievances, No Recorded Correction

    F585 was cited in September 2026. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. The most serious was level E (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F585 across all 15 inspections, oldest to newest
17. 17

    Accurate Assessments, No Recorded Correction

    F641 was cited in September 2026. This citation covers whether each resident’s assessment correctly records their condition. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F641 across all 15 inspections, oldest to newest
18. 18

    Quality of Care, No Recorded Correction

    F684 was cited in September 2024, November 2024, December 2025, March 2026 and September 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious was level J (immediate jeopardy). The September 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.

    232324242424252525252525262626F684 across all 15 inspections, oldest to newest
19. 19

    Pressure Injury Care, No Recorded Correction

    F686 was cited in September 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F686 across all 15 inspections, oldest to newest
20. 20

    Mobility and Range of Motion, No Recorded Correction

    F688 was cited in September 2024 and September 2026. This citation covers care that keeps or improves a resident’s movement and mobility. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F688 across all 15 inspections, oldest to newest
21. 21

    Respiratory Care, No Recorded Correction

    F695 was cited in September 2026. This citation covers oxygen, breathing treatments and other respiratory care. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F695 across all 15 inspections, oldest to newest
22. 22

    Citation F757, No Recorded Correction

    F757 was cited in September 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F757 across all 15 inspections, oldest to newest
23. 23

    Citation F809, No Recorded Correction

    F809 was cited in September 2026. The agency describes it this way: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. The most serious was level E (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F809 across all 15 inspections, oldest to newest
24. 24

    Medical Records, No Recorded Correction

    F842 was cited in August 2024 and September 2026. This citation covers whether resident records are complete, accurate and kept confidential. The most serious was level D (no actual harm, potential for more). The September 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.

    232324242424252525252525262626F842 across all 15 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 quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in three inspections, most seriously at level D.

2. 02

   How is a care plan written and reviewed here, and how do families take part in it?

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

3. 03

   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.

4. 04

   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.

5. 05

   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.

6. 06

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

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

7. 07

   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.

8. 08

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

   Nutrition and Hydration: cited in two inspections, most seriously at level G.

9. 09

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

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

10. 10

    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 J.

11. 11

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

    Dignity and Resident Rights: cited in two inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

12. 12

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

13. 13

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

    Needs and Preferences: cited in two inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

14. 14

    What changed after F565 was cited, and how do you check it now?

    Citation F565: cited in two inspections, most seriously at level E. The September 11, 2026 citation has no recorded correction date.

15. 15

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

    A Clean, Homelike Setting: cited in two inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

16. 16

    How do we file a grievance, who answers it, and how quickly?

    Grievances: cited in one inspections, most seriously at level E. The September 11, 2026 citation has no recorded correction date.

17. 17

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

    Accurate Assessments: cited in one inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

18. 18

    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 five inspections, most seriously at level J. The September 11, 2026 citation has no recorded correction date.

19. 19

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

    Pressure Injury Care: cited in one inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

20. 20

    What do you do to keep residents moving, and who provides range-of-motion care?

    Mobility and Range of Motion: cited in two inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

21. 21

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

    Respiratory Care: cited in one inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

22. 22

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

    Citation F757: cited in one inspections, most seriously at level D. The September 11, 2026 citation has no recorded correction date.

23. 23

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

    Citation F809: cited in one inspections, most seriously at level E. The September 11, 2026 citation has no recorded correction date.

24. 24

    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. The September 11, 2026 citation has no recorded correction date.

25. 25

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

    Insufficient nursing staff was cited in July 2025.

26. 26

    What led to the 2024 fine, and has it been paid?

    A $22,205 civil money penalty was imposed September 19, 2024. CMS publishes the fine, not whether it has been paid.

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

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

  Minnesota state survey agency

  Inspection Jul 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Nov 16, 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 Aug 13, 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 Sep 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 Nov 7, 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 5, 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 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection May 14, 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 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 15, 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 Aug 5, 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 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 Jan 27, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Minnesota state survey agency

  Inspection Mar 3, 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 Sep 11, 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 · 245187

  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.