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TheVardellReport
Warroad Care Center
Skilled nursing facility and nursing facility
1401 Lake Street Northwest
Warroad, MN 56763
Report
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The Vardell Report.Warroad Care Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Warroad, MN
- Record Period
- 2023–2025
- Source Documents
- 11
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 9 inspections from November 2023 to December 2025, state surveyors documented 47 findings at Warroad Care Center; 47 have a recorded correction; CMS lists 9 enforcement actions in the window.
- Inspections
- 9
- 2023–2025, standard and complaint
- Findings
- 47
- Deficiencies cited by state inspectors
- Corrected
- 47
- Of 47 findings, with a recorded correction date
- Penalties
- 9
- 6 fines; payment not published, 3 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 3 | 9 | 1 |
| 2024 | 3 | 30 | 3 |
| 2025 | 3 | 8 | 0 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 47 of 47 findings have a recorded correction date.
- CMS lists 9 enforcement actions in the window: 6 fines totaling $190,547, their payment not published; 3 others ended.
- 7 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, December 18, 2025, recorded 5 findings (most serious: Level F).
What to Ask About
- Investigating Alleged Violations, Cited in Three Inspections
- Dignity and Resident Rights, Cited in Two Inspections
- Protection From Abuse and Neglect, Cited in Two Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
- Citation F883, Cited in Two Inspections
Report at a Glance
- Facility
- Warroad Care Center
- Address
- 1401 Lake Street Northwest, Warroad, MN 56763
- CMS Certification Number
- 245329
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 49
- Ownership
- Non profit - Corporation
- Record Window
- November 22, 2023 to October 1, 2026
Chronology
Inspection History
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.
- 2025
Standard health inspection
5 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 Feb 2, 2026
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 2, 2026
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Feb 2, 2026
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Feb 2, 2026
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Feb 2, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- 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 Jan 9, 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 9, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- 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 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
27 findings
The same visit included a complaint investigation.
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Dec 20, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Dec 20, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- 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 FNo actual harm, potential for moreCorrected Dec 11, 2024
- F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Level FNo actual harm, potential for moreCorrected Dec 11, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- 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 Dec 20, 2024
- 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 Dec 20, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Dec 20, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Dec 20, 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 ENo actual harm, potential for moreCorrected Dec 20, 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 Dec 20, 2024
- 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 Dec 20, 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 20, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 20, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 11, 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 11, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Dec 20, 2024
- F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Level CPotential for minimal harmCorrected Dec 20, 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 Dec 11, 2024
Enforcement Action
Civil money penalty, $145,889 imposed November 6, 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 November 6, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 6, 2024. Status: Closed, December 20, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 6, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 9, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 9, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- 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 JImmediate jeopardyCorrected Jul 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
3 findings
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 22, 2023
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 22, 2023
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Dec 22, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
4 findings
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Dec 22, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Dec 22, 2023
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Dec 22, 2023
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Dec 22, 2023
Enforcement Action
Civil money penalty, $8,469 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 standard health inspection of November 29, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $3,529 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 standard health inspection of November 29, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $16,187 imposed June 13, 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 November 29, 2023, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed June 13, 2024. Status: Closed, July 11, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 29, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 15, 2023
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Dec 15, 2023
Enforcement Action
Civil money penalty, $5,293 imposed November 6, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey, and no survey before the penalty date is in this release; listed with the earliest, November 22, 2023.
Enforcement Action
Civil money penalty, $11,180 imposed November 22, 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 November 22, 2023, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 22, 2023. Status: Closed, December 22, 2023. CMS does not tie a penalty to a survey; listed with the complaint investigation of November 22, 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.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Investigating Alleged Violations, Cited in Three Inspections
Inspectors cited F610 in December 2023, July 2024 and November 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.
232323242424252525F610 across all 9 inspections, oldest to newest - 2
Dignity and Resident Rights, Cited in Two Inspections
Inspectors cited F550 in November 2024 and March 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.
232323242424252525F550 across all 9 inspections, oldest to newest - 3
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in November 2024 and December 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525F600 across all 9 inspections, oldest to newest - 4
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in December 2023 and November 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.
232323242424252525F609 across all 9 inspections, oldest to newest - 5
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in November 2023 and November 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525F689 across all 9 inspections, oldest to newest - 6
Infection Control, Cited in Two Inspections
Inspectors cited F880 in November 2024 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.
232323242424252525F880 across all 9 inspections, oldest to newest - 7
Citation F883, Cited in Two Inspections
Inspectors cited F883 in November 2023 and December 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.
232323242424252525F883 across all 9 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in three inspections, most seriously at level D.
- 02
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.
- 03
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level J.
- 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.
- 05
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 two inspections, most seriously at level J.
- 06
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level F.
- 07
What changed after F883 was cited, and how do you check it now?
Citation F883: cited in two inspections, most seriously at level E.
- 08
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 November 2024.
- 09
What led to the 2024 fine, and has it been paid?
A $145,889 civil money penalty was imposed November 6, 2024. CMS publishes the fine, not whether it has been paid. The record holds nine enforcement actions in the window.
The Evidence
Sources and Coverage
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 Nov 22, 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 29, 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 6, 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 Jun 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 Jul 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Nov 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 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 Dec 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Minnesota state survey agency
Inspection Dec 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 245329
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowNovember 22, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before November 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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