The Vardell Report.Lotus Village Center for Nursing and Rehabilitatio

Across 9 inspections from February 2024 to May 2026, state surveyors documented 52 findings at Lotus Village Center for Nursing and Rehabilitatio; 52 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

9

2024–2026, standard and complaint

Findings

52

Deficiencies cited by state inspectors

Corrected

52

Of 52 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. May 152026

   Standard health inspection

   15 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 Jan 10, 2026
   • 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 Jun 15, 2026
   • 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 Jun 15, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • 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 Jun 15, 2026
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 15, 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 Jun 15, 2026
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • 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 Jun 15, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 15, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jun 15, 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 Jun 15, 2026

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

2. Mar 192026

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 15, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jun 15, 2026

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

3. May 222025

   Standard health inspection

   6 findings

   The same visit included a complaint investigation.

   • 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 Jun 13, 2025
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Jun 13, 2025
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Jun 13, 2025
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Jun 13, 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 Jun 13, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 13, 2025

   Enforcement Action

   Civil money penalty, $14,524 imposed March 19, 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 May 22, 2025, the nearest before the penalty date.

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

4. Apr 102025

   Complaint investigation

   4 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level GActual harmCorrected May 22, 2025
   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected May 22, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 22, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 22, 2025

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

5. Oct 242024

   Complaint investigation

   1 finding

   • 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 25, 2024

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

6. Sep 272024

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Sep 20, 2024

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

7. Aug 72024

   Complaint investigation

   3 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • 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 Aug 29, 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 Aug 29, 2024

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

8. Apr 82024

   Complaint investigation

   4 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level KImmediate jeopardyCorrected May 4, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level KImmediate jeopardyCorrected May 4, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level JImmediate jeopardyCorrected May 4, 2024
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected May 4, 2024

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

9. Feb 222024

   Standard health inspection

   16 findings

   The same visit included a complaint investigation.

   • 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 FNo actual harm, potential for moreCorrected May 4, 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 May 4, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected May 4, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 4, 2024
   • 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 May 4, 2024
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected May 4, 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 May 4, 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 May 4, 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 DNo actual harm, potential for moreCorrected May 4, 2024
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 4, 2024
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level BPotential for minimal harmCorrected May 4, 2024

   Enforcement Action

   Civil money penalty, $197,071 imposed February 22, 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 22, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $16,055 imposed September 27, 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 22, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $102,102 imposed April 10, 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 22, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 10, 2025. Status: Closed, June 13, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 22, 2024, 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

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in August 2024, September 2024, October 2024 and May 2026. 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.

   242424242425252626F689 across all 9 inspections, oldest to newest
2. 2

   Telling Families About Changes, Cited in Three Inspections

   Inspectors cited F580 in April 2024, August 2024 and April 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. 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.

   242424242425252626F580 across all 9 inspections, oldest to newest
3. 3

   Accurate Assessments, Cited in Three Inspections

   Inspectors cited F641 in February 2024, April 2025 and May 2026. This citation covers whether each resident’s assessment correctly records their condition. 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.

   242424242425252626F641 across all 9 inspections, oldest to newest
4. 4

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in April 2024, April 2025 and March 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424242425252626F684 across all 9 inspections, oldest to newest
5. 5

   Continence and Catheter Care, Cited in Three Inspections

   Inspectors cited F690 in February 2024, May 2025 and May 2026. 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.

   242424242425252626F690 across all 9 inspections, oldest to newest
6. 6

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in February 2024, May 2025 and May 2026. 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.

   242424242425252626F761 across all 9 inspections, oldest to newest
7. 7

   Treatment Choices and Advance Directives, Cited in Two Inspections

   Inspectors cited F578 in February 2024 and May 2026. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. 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.

   242424242425252626F578 across all 9 inspections, oldest to newest
8. 8

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in April 2024 and August 2024. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424242425252626F600 across all 9 inspections, oldest to newest
9. 9

   Citation F636, Cited in Two Inspections

   Inspectors cited F636 in May 2025 and May 2026. The agency describes it this way: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. 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.

   242424242425252626F636 across all 9 inspections, oldest to newest
10. 10

    Citation F638, Cited in Two Inspections

    Inspectors cited F638 in May 2025 and May 2026. The agency describes it this way: Assure that each resident’s assessment is updated at least once every 3 months. 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.

    242424242425252626F638 across all 9 inspections, oldest to newest
11. 11

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in February 2024 and May 2026. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    242424242425252626F656 across all 9 inspections, oldest to newest
12. 12

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in March 2026 and May 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    242424242425252626F842 across all 9 inspections, oldest to newest
13. 13

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in February 2024 and April 2024. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. 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.

    242424242425252626F867 across all 9 inspections, oldest to newest
14. 14

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in February 2024 and May 2026. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. 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.

    242424242425252626F883 across all 9 inspections, oldest to newest
15. 15

    Citation F887, Cited in Two Inspections

    Inspectors cited F887 in February 2024 and May 2026. The agency describes it this way: Educate 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. 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.

    242424242425252626F887 across all 9 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 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 four inspections, most seriously at level J.

2. 02

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

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

3. 03

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

   Accurate Assessments: cited in three inspections, most seriously at level D.

4. 04

   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 K.

5. 05

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

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

6. 06

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

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

7. 07

   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 F.

8. 08

   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 K.

9. 09

   What changed after F636 was cited, and how do you check it now?

   Citation F636: cited in two inspections, most seriously at level D.

10. 10

    What changed after F638 was cited, and how do you check it now?

    Citation F638: cited in two inspections, most seriously at level D.

11. 11

    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 E.

12. 12

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

13. 13

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

14. 14

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level D.

15. 15

    What changed after F887 was cited, and how do you check it now?

    Citation F887: cited in two inspections, most seriously at level E.

16. 16

    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 February 2024.

17. 17

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

    A $14,524 civil money penalty was imposed March 19, 2026. 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 North Carolina state survey agency.

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

  North Carolina 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)

  North Carolina state survey agency

  Inspection Apr 8, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection Aug 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection Sep 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection Oct 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection Apr 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection May 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection Mar 19, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  North Carolina state survey agency

  Inspection May 15, 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 · 345261

  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.