The Vardell Report.Magnolia Wellness Center

Across 14 inspections from September 2019 to June 2026, state surveyors documented 84 findings at Magnolia Wellness Center; 82 have a recorded correction and 2 await one; CMS lists 11 enforcement actions in the window.

Inspections

14

2019–2026, complaint and standard

Findings

84

Deficiencies cited by state inspectors

Corrected

82

Of 84 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 122026

   Complaint investigation

   3 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jul 16, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jul 16, 2026
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 16, 2026

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

2. Apr 92026

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 10, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 10, 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 Mar 17, 2026
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Apr 10, 2026

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

3. Dec 122025

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 10, 2026
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level ENo actual harm, potential for moreCorrected Apr 10, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Dec 13, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 10, 2026

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

4. Oct 242025

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmPast Non-Compliance

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

5. Aug 72025

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for morePast Non-Compliance

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

6. Jun 252025

   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 Jun 23, 2025

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

7. May 22025

   Complaint investigation

   2 findings

   • 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 May 3, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 3, 2025

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

8. Mar 262025

   Complaint investigation

   5 findings

   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Apr 22, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 2, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 3, 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 May 3, 2025

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

9. Mar 42025

   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 GActual harmCorrected Mar 5, 2025
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Mar 5, 2025

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

10. Jul 22024

    Complaint investigation

    1 finding

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jun 29, 2024

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

11. May 22024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jun 15, 2024

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

12. Feb 152024

    Standard health inspection

    13 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 JImmediate jeopardyCorrected Mar 29, 2024
    • 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 Mar 29, 2024
    • F567Honor the resident's right to manage his or her financial affairs.Level ENo actual harm, potential for moreCorrected Mar 29, 2024
    • 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 Mar 29, 2024
    • 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 Mar 29, 2024
    • 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 Mar 29, 2024
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Mar 29, 2024
    • 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 Mar 29, 2024
    • 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 29, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 29, 2024
    • 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 DNo actual harm, potential for moreCorrected Mar 29, 2024
    • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level DNo actual harm, potential for moreCorrected Mar 29, 2024
    • F680Ensure the activities program is directed by a qualified professional.Level CPotential for minimal harmCorrected Mar 29, 2024

    Enforcement Action

    Civil money penalty, $17,091 imposed February 15, 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 February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $139,544 imposed May 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 February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed May 2, 2024. Status: Closed, June 15, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $40,717 imposed March 4, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 4, 2025. Status: Closed, May 3, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $12,438 imposed October 24, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $15,935 imposed December 12, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $26,685 imposed December 12, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed December 12, 2025. Status: Closed, April 10, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $152,190 imposed June 12, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed June 12, 2026. Status: Closed, August 4, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.

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

13. Dec 82021

    Standard health inspection

    29 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jan 22, 2022
    • F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Jan 22, 2022
    • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Jan 22, 2022
    • 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 Apr 30, 2022
    • 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 Jan 22, 2022
    • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Jan 22, 2022
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jan 22, 2022
    • F564Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • 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 ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 30, 2022
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • 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 30, 2022
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Apr 30, 2022
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Jan 22, 2022
    • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level ENo actual harm, potential for moreCorrected Apr 30, 2022
    • 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 ENo actual harm, potential for moreCorrected Apr 30, 2022
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 30, 2022
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 30, 2022
    • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jan 22, 2022
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 22, 2022
    • 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, 2022
    • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Jan 22, 2022
    • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jan 22, 2022
    • F888Ensure staff are vaccinated for COVID-19Level CPotential for minimal harmCorrected Apr 30, 2022

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

14. Sep 62019

    Standard health inspection

    17 findings

    • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level ENo actual harm, potential for moreCorrected Oct 18, 2019
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level ENo actual harm, potential for moreCorrected Oct 18, 2019
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Oct 18, 2019
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Oct 18, 2019
    • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Oct 18, 2019
    • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 30, 2019
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • 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 18, 2019
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 18, 2019
    • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Oct 18, 2019
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level BPotential for minimal harmCorrected Oct 18, 2019
    • F641Ensure each resident receives an accurate assessment.Level BPotential for minimal harmCorrected Oct 18, 2019

    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

   Citation F740, Cited in Four Inspections

   Inspectors cited F740 in December 2021, March 2025, December 2025 and April 2026. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921242424252525252525252626F740 across all 14 inspections, oldest to newest
2. 2

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in September 2019, December 2021 and June 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   1921242424252525252525252626F584 across all 14 inspections, oldest to newest
3. 3

   Investigating Alleged Violations, Cited in Three Inspections

   Inspectors cited F610 in December 2021, December 2025 and April 2026. 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.

   1921242424252525252525252626F610 across all 14 inspections, oldest to newest
4. 4

   Professional Standards, Cited in Three Inspections

   Inspectors cited F658 in September 2019, December 2021 and March 2025. This citation covers whether the home’s services meet professional standards of quality. 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.

   1921242424252525252525252626F658 across all 14 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in May 2024, March 2025 and May 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921242424252525252525252626F684 across all 14 inspections, oldest to newest
6. 6

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in September 2019, December 2021 and June 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1921242424252525252525252626F686 across all 14 inspections, oldest to newest
7. 7

   Mobility and Range of Motion, Cited in Three Inspections

   Inspectors cited F688 in September 2019, March 2025 and May 2025. This citation covers care that keeps or improves a resident’s movement and mobility. 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.

   1921242424252525252525252626F688 across all 14 inspections, oldest to newest
8. 8

   Pharmacy Services, Cited in Three Inspections

   Inspectors cited F755 in December 2021, February 2024 and December 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.

   1921242424252525252525252626F755 across all 14 inspections, oldest to newest
9. 9

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in September 2019, December 2021 and March 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.

   1921242424252525252525252626F880 across all 14 inspections, oldest to newest
10. 10

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in September 2019 and June 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.

    1921242424252525252525252626F550 across all 14 inspections, oldest to newest
11. 11

    Treatment Choices and Advance Directives, Cited in Two Inspections

    Inspectors cited F578 in September 2019 and December 2021. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. 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.

    1921242424252525252525252626F578 across all 14 inspections, oldest to newest
12. 12

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in September 2019 and December 2021. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

    1921242424252525252525252626F677 across all 14 inspections, oldest to newest
13. 13

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

    Inspectors cited F679 in September 2019 and December 2021. The agency describes it this way: Provide activities to meet all resident's needs. 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.

    1921242424252525252525252626F679 across all 14 inspections, oldest to newest
14. 14

    Citation F680, Cited in Two Inspections

    Inspectors cited F680 in December 2021 and February 2024. The agency describes it this way: Ensure the activities program is directed by a qualified professional. 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.

    1921242424252525252525252626F680 across all 14 inspections, oldest to newest
15. 15

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in September 2019 and December 2021. 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.

    1921242424252525252525252626F692 across all 14 inspections, oldest to newest
16. 16

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in December 2021 and March 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.

    1921242424252525252525252626F759 across all 14 inspections, oldest to newest
17. 17

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in September 2019 and December 2021. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1921242424252525252525252626F761 across all 14 inspections, oldest to newest
18. 18

    Protection From Abuse and Neglect, No Recorded Correction

    F600 was cited in July 2024, March 2025 and August 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious was level G (actual harm). The August 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    1921242424252525252525252626F600 across all 14 inspections, oldest to newest
19. 19

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in September 2019, February 2024, October 2025, December 2025, April 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 J (immediate jeopardy). The October 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    1921242424252525252525252626F689 across all 14 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

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

   Citation F740: cited in four inspections, most seriously at level E.

2. 02

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

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

3. 03

   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.

4. 04

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

   Professional Standards: cited in three inspections, most seriously at level E.

5. 05

   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 J.

6. 06

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

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

7. 07

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

   Mobility and Range of Motion: cited in three inspections, most seriously at level E.

8. 08

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

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

9. 09

   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.

10. 10

    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.

11. 11

    How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

    Treatment Choices and Advance Directives: cited in two inspections, most seriously at level E.

12. 12

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level D.

13. 13

    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 F.

14. 14

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

    Citation F680: cited in two inspections, most seriously at level F.

15. 15

    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 D.

16. 16

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level E.

17. 17

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

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

18. 18

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

    Protection From Abuse and Neglect: cited in three inspections, most seriously at level G. The August 7, 2025 citation has no recorded correction date.

19. 19

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in six inspections, most seriously at level J. The October 24, 2025 citation has no recorded correction date.

20. 20

    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 2021.

21. 21

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

    A $152,190 civil money penalty was imposed June 12, 2026. CMS publishes the fine, not whether it has been paid. 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 Missouri state survey agency.

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

  Missouri state survey agency

  Inspection Sep 6, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Dec 8, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

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

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

  Missouri state survey agency

  Inspection May 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Jul 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

  Inspection Mar 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)

  Missouri state survey agency

  Inspection Mar 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)

  Missouri state survey agency

  Inspection May 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)

  Missouri state survey agency

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

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

  Missouri state survey agency

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

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

  Missouri state survey agency

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

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

  Missouri state survey agency

  Inspection Dec 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Missouri state survey agency

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

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

  Missouri state survey agency

  Inspection Jun 12, 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 · 265672

  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.