The Vardell Report.Cooney Healthcare and Rehabilitation

Across 10 inspections from August 2023 to December 2025, state surveyors documented 76 findings at Cooney Healthcare and Rehabilitation; 76 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

10

2023–2025, complaint and standard

Findings

76

Deficiencies cited by state inspectors

Corrected

76

Of 76 findings, with a recorded correction date

Penalties

5

4 fines; payment not published, 1 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. Dec 312025

   Complaint investigation

   2 findings

   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jan 23, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 23, 2026

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

2. Dec 42025

   Complaint investigation

   7 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 15, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level FNo actual harm, potential for moreCorrected Dec 15, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level FNo actual harm, potential for moreCorrected Dec 15, 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 FNo actual harm, potential for moreCorrected Dec 15, 2025
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Dec 15, 2025
   • 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 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 15, 2025

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

3. Sep 112025

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Oct 24, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Oct 24, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Oct 24, 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 FNo actual harm, potential for moreCorrected Oct 24, 2025
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Oct 24, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 24, 2025
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 24, 2025
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level ENo actual harm, potential for moreCorrected Aug 1, 2025
   • 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 ENo actual harm, potential for moreCorrected Oct 24, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Oct 24, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Oct 24, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • 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 Oct 24, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Oct 24, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Oct 24, 2025

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

4. Aug 62025

   Complaint investigation

   5 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Sep 19, 2025
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Sep 19, 2025
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level ENo actual harm, potential for moreCorrected Sep 19, 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 Sep 19, 2025
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Sep 19, 2025

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

5. Oct 32024

   Complaint investigation

   3 findings

   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Oct 31, 2024
   • 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 ENo actual harm, potential for moreCorrected 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 Oct 31, 2024

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

6. Aug 152024

   Standard health inspection

   12 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Sep 9, 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 Sep 9, 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 Sep 9, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 9, 2024
   • 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 Sep 9, 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 Sep 9, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Sep 9, 2024

   Enforcement Action

   Civil money penalty, $44,363 imposed August 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 August 15, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $14,505 imposed August 6, 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 August 15, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $101,533 imposed August 6, 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 August 15, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed August 6, 2025. Status: Closed, December 15, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 15, 2024, the nearest before the penalty date.

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

7. May 22024

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected May 21, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level GActual harmCorrected May 21, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 21, 2024

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

8. Feb 222024

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 29, 2024

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

9. Jan 162024

   Complaint investigation

   2 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 29, 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 Feb 29, 2024

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

10. Aug 172023

    Standard health inspection

    21 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Sep 21, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Sep 21, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level GActual harmCorrected Sep 21, 2023
    • 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 FNo actual harm, potential for moreCorrected Sep 28, 2023
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level ENo actual harm, potential for moreCorrected Sep 21, 2023
    • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Sep 21, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Sep 21, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 21, 2023
    • 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 Sep 21, 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 21, 2023
    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Sep 21, 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 Sep 21, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 21, 2023
    • 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 Sep 21, 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 21, 2023
    • 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 Sep 21, 2023
    • 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 Sep 21, 2023
    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Sep 21, 2023
    • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Sep 21, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Sep 21, 2023
    • 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 Sep 21, 2023

    Enforcement Action

    Civil money penalty, $52,735 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 August 17, 2023, the nearest before the penalty date.

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

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Reporting Suspected Abuse, Cited in Four Inspections

   Inspectors cited F609 in August 2023, October 2024, September 2025 and December 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.

   23242424242425252525F609 across all 10 inspections, oldest to newest
2. 2

   Nursing Staff Levels, Cited in Four Inspections

   Inspectors cited F725 in August 2023, August 2024, September 2025 and December 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. 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.

   23242424242425252525F725 across all 10 inspections, oldest to newest
3. 3

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in August 2023, January 2024 and September 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.

   23242424242425252525F550 across all 10 inspections, oldest to newest
4. 4

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in August 2023, August 2024 and September 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252525F657 across all 10 inspections, oldest to newest
5. 5

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in February 2024, August 2024 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252525F686 across all 10 inspections, oldest to newest
6. 6

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in August 2024, August 2025 and September 2025. 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252525F689 across all 10 inspections, oldest to newest
7. 7

   Nutrition and Hydration, Cited in Three Inspections

   Inspectors cited F692 in August 2023, August 2024 and September 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.

   23242424242425252525F692 across all 10 inspections, oldest to newest
8. 8

   Citation F726, Cited in Three Inspections

   Inspectors cited F726 in October 2024, August 2025 and September 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252525F726 across all 10 inspections, oldest to newest
9. 9

   Medication Error Rate, Cited in Three Inspections

   Inspectors cited F759 in August 2023, August 2024 and September 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.

   23242424242425252525F759 across all 10 inspections, oldest to newest
10. 10

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in August 2023, August 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252525F880 across all 10 inspections, oldest to newest
11. 11

    Grievances, Cited in Two Inspections

    Inspectors cited F585 in January 2024 and December 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. 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.

    23242424242425252525F585 across all 10 inspections, oldest to newest
12. 12

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in August 2023 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252525F600 across all 10 inspections, oldest to newest
13. 13

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in August 2025 and September 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. 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.

    23242424242425252525F610 across all 10 inspections, oldest to newest
14. 14

    The First 48 Hours, Cited in Two Inspections

    Inspectors cited F655 in August 2023 and December 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.

    23242424242425252525F655 across all 10 inspections, oldest to newest
15. 15

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in August 2023 and August 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.

    23242424242425252525F656 across all 10 inspections, oldest to newest
16. 16

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in May 2024 and December 2025. This citation covers whether the home’s services meet professional standards of quality. 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.

    23242424242425252525F658 across all 10 inspections, oldest to newest
17. 17

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in May 2024 and December 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.

    23242424242425252525F684 across all 10 inspections, oldest to newest
18. 18

    Continence and Catheter Care, Cited in Two Inspections

    Inspectors cited F690 in August 2023 and September 2025. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

    23242424242425252525F690 across all 10 inspections, oldest to newest
19. 19

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in August 2023 and May 2024. This citation covers oxygen, breathing treatments and other respiratory care. 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.

    23242424242425252525F695 across all 10 inspections, oldest to newest
20. 20

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in August 2023 and September 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. 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.

    23242424242425252525F761 across all 10 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 are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in four inspections, most seriously at level D.

2. 02

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

   Nursing Staff Levels: cited in four inspections, most seriously at level F.

3. 03

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

   Dignity and Resident Rights: cited in three inspections, most seriously at level D.

4. 04

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

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

5. 05

   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.

6. 06

   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 three inspections, most seriously at level G.

7. 07

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

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

8. 08

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

   Citation F726: cited in three inspections, most seriously at level E.

9. 09

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

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

10. 10

    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.

11. 11

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

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

12. 12

    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 G.

13. 13

    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 E.

14. 14

    What happens in the first 48 hours after admission, and who writes the first care plan?

    The First 48 Hours: cited in two inspections, most seriously at level E.

15. 15

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

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

16. 16

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

    Professional Standards: cited in two inspections, most seriously at level F.

17. 17

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

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

18. 18

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

    Continence and Catheter Care: cited in two inspections, most seriously at level D.

19. 19

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

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

20. 20

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

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

21. 21

    What led to the 2025 fine, and has it been paid?

    A $14,505 civil money penalty was imposed August 6, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

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

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

  Montana state survey agency

  Inspection Aug 17, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana state survey agency

  Inspection Jan 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana state survey agency

  Inspection Feb 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana 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)

  Montana state survey agency

  Inspection Aug 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)

  Montana state survey agency

  Inspection Oct 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana state survey agency

  Inspection Aug 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana state survey agency

  Inspection Sep 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Montana 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)

  Montana state survey agency

  Inspection Dec 31, 2025 · 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 · 275080

  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.