The Vardell Report.Avantara Norton

Across 19 inspections from October 2023 to March 2026, state surveyors documented 75 findings at Avantara Norton; 71 have a recorded correction and 4 await one; CMS lists 7 enforcement actions in the window.

Inspections

19

2023–2026, standard and complaint

Findings

75

Deficiencies cited by state inspectors

Corrected

71

Of 75 findings, with a recorded correction date

Penalties

7

7 fines; payment not published

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

1. Mar 312026

   Standard health inspection

   15 findings

   The same visit included a complaint investigation.

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected May 8, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected May 8, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 8, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected May 8, 2026
   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected May 8, 2026
   • 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 8, 2026
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected May 8, 2026
   • 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 May 8, 2026
   • 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 8, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 8, 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 May 8, 2026
   • 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 May 8, 2026
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Dec 10, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected May 8, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 8, 2026

   Enforcement Action

   Civil money penalty, $96,750 imposed March 31, 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 March 31, 2026, the nearest before the penalty date.

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

2. Feb 42026

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jan 16, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Mar 6, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 6, 2026

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

3. Dec 302025

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for morePast Non-Compliance
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.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)

4. Nov 142025

   Complaint investigation

   1 finding

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 12, 2025

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

5. Jul 102025

   Complaint investigation

   4 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected May 1, 2025
   • 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 May 28, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Aug 4, 2025
   • 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 Jun 7, 2025

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

6. Apr 102025

   Complaint investigation

   3 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreDeficient, Provider has date of correction
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Apr 9, 2025
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreDeficient, Provider has date of correction

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

7. Mar 52025

   Standard health inspection

   9 findings

   The same visit included a complaint investigation.

   • F675Honor each resident's preferences, choices, values and beliefs.Level HActual harmCorrected Apr 4, 2025
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
   • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level ENo actual harm, potential for moreCorrected Apr 4, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 4, 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 Apr 4, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 4, 2025

   Enforcement Action

   Civil money penalty, $51,376 imposed March 5, 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 March 5, 2025, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $61,845 imposed February 4, 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 March 5, 2025, the nearest before the penalty date.

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

8. Dec 272024

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 10, 2025

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

9. Nov 142024

   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 Dec 11, 2024

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

10. Oct 292024

    Complaint investigation

    2 findings

    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level GActual harmCorrected Nov 27, 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 Nov 27, 2024

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

11. Sep 262024

    Complaint investigation

    1 finding

    • 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 Nov 10, 2024

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

12. Aug 212024

    Complaint investigation

    3 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Sep 20, 2024
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Sep 20, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 20, 2024

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

13. Jul 172024

    Complaint investigation

    1 finding

    • 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 Aug 26, 2024

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

14. Jun 202024

    Complaint investigation

    2 findings

    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level GActual harmCorrected May 30, 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 May 30, 2024

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

15. Apr 162024

    Complaint investigation

    1 finding

    • 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 Apr 14, 2024

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

16. Mar 132024

    Complaint investigation

    3 findings

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 8, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Apr 8, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 8, 2024

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

17. Dec 142023

    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 Jan 11, 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 Jan 11, 2024

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

18. Nov 92023

    Standard health inspection

    19 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 KImmediate jeopardyCorrected Dec 7, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level HActual harmCorrected Dec 14, 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 HActual harmCorrected Dec 7, 2023
    • 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 HActual harmCorrected Dec 7, 2023
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Dec 14, 2023
    • F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Dec 14, 2023
    • 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 Dec 14, 2023
    • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Dec 14, 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 ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Dec 14, 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 ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level ENo actual harm, potential for moreCorrected Dec 14, 2023
    • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Dec 14, 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 Dec 14, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 14, 2023
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 14, 2023

    Enforcement Action

    Civil money penalty, $37,557 imposed March 13, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 9, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $12,035 imposed June 20, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 9, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $12,035 imposed July 17, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 9, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $12,035 imposed September 26, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 9, 2023, the nearest before the penalty date.

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

19. Oct 42023

    Complaint investigation

    2 findings

    • 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 Dec 14, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 14, 2023

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

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

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

1. 1

   Pressure Injury Care, Cited in Five Inspections

   Inspectors cited F686 in November 2023, August 2024, July 2025, February 2026 and March 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level H (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232324242424242424242425252525252626F686 across all 19 inspections, oldest to newest
2. 2

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in November 2023, March 2025, November 2025 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.

   23232324242424242424242425252525252626F880 across all 19 inspections, oldest to newest
3. 3

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in December 2023, June 2024 and March 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.

   23232324242424242424242425252525252626F550 across all 19 inspections, oldest to newest
4. 4

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in November 2024, July 2025 and March 2026. This citation covers whether residents are protected from abuse and neglect by anyone. 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.

   23232324242424242424242425252525252626F600 across all 19 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in December 2024, February 2026 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 G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232324242424242424242425252525252626F684 across all 19 inspections, oldest to newest
6. 6

   Citation F726, Cited in Three Inspections

   Inspectors cited F726 in November 2023, April 2024 and October 2024. 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. The most serious of these was recorded at level H (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232324242424242424242425252525252626F726 across all 19 inspections, oldest to newest
7. 7

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in July 2024, March 2025 and March 2026. This citation covers how food is stored, prepared and served. 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.

   23232324242424242424242425252525252626F812 across all 19 inspections, oldest to newest
8. 8

   Citation F561, Cited in Two Inspections

   Inspectors cited F561 in November 2023 and March 2026. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 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.

   23232324242424242424242425252525252626F561 across all 19 inspections, oldest to newest
9. 9

   The First 48 Hours, Cited in Two Inspections

   Inspectors cited F655 in September 2024 and March 2026. 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.

   23232324242424242424242425252525252626F655 across all 19 inspections, oldest to newest
10. 10

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in November 2023 and March 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.

    23232324242424242424242425252525252626F656 across all 19 inspections, oldest to newest
11. 11

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in November 2023 and October 2024. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242424242425252525252626F657 across all 19 inspections, oldest to newest
12. 12

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in March 2024 and March 2026. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. 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.

    23232324242424242424242425252525252626F697 across all 19 inspections, oldest to newest
13. 13

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in August 2024 and March 2026. This citation covers whether residents are free from significant medication errors. 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.

    23232324242424242424242425252525252626F760 across all 19 inspections, oldest to newest
14. 14

    Administration, Cited in Two Inspections

    Inspectors cited F835 in November 2023 and March 2025. This citation covers whether the home is run in a way that uses its resources effectively. 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.

    23232324242424242424242425252525252626F835 across all 19 inspections, oldest to newest
15. 15

    Citation F837, Cited in Two Inspections

    Inspectors cited F837 in November 2023 and March 2025. The agency describes it this way: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. 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.

    23232324242424242424242425252525252626F837 across all 19 inspections, oldest to newest
16. 16

    Citation F624, No Recorded Correction

    F624 was cited in April 2025. The agency describes it this way: Prepare residents for a safe transfer or discharge from the nursing home. The most serious was level D (no actual harm, potential for more). The April 2025 citation has no recorded correction date; its status reads “Deficient, Provider has date of correction.” The record does not show whether the problem was fixed.

    23232324242424242424242425252525252626F624 across all 19 inspections, oldest to newest
17. 17

    Professional Standards, No Recorded Correction

    F658 was cited in November 2023, March 2024, March 2025, April 2025 and July 2025. This citation covers whether the home’s services meet professional standards of quality. The most serious was level E (no actual harm, potential for more). The April 2025 citation has no recorded correction date; its status reads “Deficient, Provider has date of correction.” The record does not show whether the problem was fixed.

    23232324242424242424242425252525252626F658 across all 19 inspections, oldest to newest
18. 18

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in November 2023, March 2024, July 2025, December 2025, February 2026 and March 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 K (immediate jeopardy). The December 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    23232324242424242424242425252525252626F689 across all 19 inspections, oldest to newest
19. 19

    Food Quality and Temperature, No Recorded Correction

    F804 was cited in August 2024 and December 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. The most serious was level E (no actual harm, potential for more). The December 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

    23232324242424242424242425252525252626F804 across all 19 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 often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in five inspections, most seriously at level H.

2. 02

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in four inspections, most seriously at level E.

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 G.

4. 04

   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 D.

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 G.

6. 06

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

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

7. 07

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

8. 08

   What changed after F561 was cited, and how do you check it now?

   Citation F561: cited in two inspections, most seriously at level E.

9. 09

   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.

10. 10

    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.

11. 11

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

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

12. 12

    What changed after F697 was cited, and how do you check it now?

    Citation F697: cited in two inspections, most seriously at level G.

13. 13

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in two inspections, most seriously at level G.

14. 14

    How long have the administrator and the director of nursing been in their roles?

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

15. 15

    What changed after F837 was cited, and how do you check it now?

    Citation F837: cited in two inspections, most seriously at level F.

16. 16

    What changed after F624 was cited, and how do you check it now?

    Citation F624: cited in one inspections, most seriously at level D. The April 10, 2025 citation has no recorded correction date.

17. 17

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

    Professional Standards: cited in five inspections, most seriously at level E. The April 10, 2025 citation has no recorded correction date.

18. 18

    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 K. The December 30, 2025 citation has no recorded correction date.

19. 19

    May we try a meal, and how do you check food temperature by the time it reaches residents?

    Food Quality and Temperature: cited in two inspections, most seriously at level E. The December 30, 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 November 2023.

21. 21

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

    A $96,750 civil money penalty was imposed March 31, 2026. CMS publishes the fine, not whether it has been paid. The record holds seven enforcement actions in the window.

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

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

  South Dakota state survey agency

  Inspection Oct 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Nov 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

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

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

  South Dakota state survey agency

  Inspection Mar 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Apr 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)

  South Dakota state survey agency

  Inspection Jun 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Jul 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Aug 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Sep 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Oct 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Nov 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Dec 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)

  South Dakota state survey agency

  Inspection Mar 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota 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)

  South Dakota state survey agency

  Inspection Jul 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)

  South Dakota state survey agency

  Inspection Nov 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Dec 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Feb 4, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  South Dakota state survey agency

  Inspection Mar 31, 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 · 435039

  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.