The Vardell Report.Bayshore Nursing & Rehab

Across 13 inspections from March 2023 to April 2026, state surveyors documented 128 findings at Bayshore Nursing & Rehab; 128 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

13

2023–2026, complaint and standard

Findings

128

Deficiencies cited by state inspectors

Corrected

128

Of 128 findings, with a recorded correction date

Penalties

3

1 fine; payment not published, 2 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. Apr 302026

   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 DNo actual harm, potential for moreCorrected May 22, 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 May 22, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 22, 2026
   • 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 May 22, 2026

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

2. Sep 302025

   Standard health inspection

   39 findings

   The same visit included a complaint investigation.

   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level LImmediate jeopardyCorrected Nov 12, 2025
   • F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Level LImmediate jeopardyCorrected Nov 12, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Nov 12, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Nov 12, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Nov 12, 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 Nov 12, 2025
   • 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 Nov 12, 2025
   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 Nov 12, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 FNo actual harm, potential for moreCorrected Nov 12, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Nov 12, 2025
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected Nov 12, 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 ENo actual harm, potential for moreCorrected Nov 12, 2025
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 Nov 12, 2025
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Nov 12, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 Nov 12, 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 Nov 12, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Nov 12, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 DNo actual harm, potential for moreCorrected Nov 12, 2025
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Nov 12, 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 Nov 12, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 12, 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 Nov 12, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Nov 12, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 Nov 12, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • 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 Nov 12, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Nov 12, 2025
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Nov 12, 2025

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

3. Jul 302025

   Complaint investigation

   1 finding

   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 26, 2025

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

4. Jul 282025

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Nov 14, 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 Aug 26, 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 Aug 26, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 26, 2025

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

5. Jul 32025

   Complaint investigation

   15 findings

   • F692Provide enough food/fluids to maintain a resident's health.Level JImmediate jeopardyCorrected Nov 14, 2025
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Aug 25, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Aug 25, 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 Aug 25, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 25, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 25, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Aug 25, 2025

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

6. May 292025

   Complaint investigation

   9 findings

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 27, 2025
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jun 27, 2025
   • 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 DNo actual harm, potential for moreCorrected Jun 27, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 27, 2025
   • 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 Jun 27, 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 Jun 27, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 27, 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 27, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 27, 2025

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

7. Jan 292025

   Complaint investigation

   6 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 FNo actual harm, potential for moreCorrected Feb 27, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
   • 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 Feb 27, 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 DNo actual harm, potential for moreCorrected Feb 27, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 27, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 27, 2025

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

8. Oct 302024

   Complaint investigation

   4 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 FNo actual harm, potential for moreCorrected Feb 27, 2025
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Dec 2, 2024
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Dec 2, 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 Dec 2, 2024

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

9. Jul 242024

   Complaint investigation

   1 finding

   • 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 Aug 15, 2024

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

10. Jun 202024

    Standard health inspection

    12 findings

    The same visit included a complaint investigation.

    • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Jul 25, 2024
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jul 25, 2024
    • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Jul 25, 2024
    • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 25, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 25, 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 Jul 25, 2024
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jul 25, 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 Jul 25, 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 Jul 25, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 25, 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 Jul 25, 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 Jul 25, 2024

    Enforcement Action

    Denial of payment imposed October 30, 2024. Status: Closed, February 27, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 20, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $424,350 imposed May 29, 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 June 20, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed May 29, 2025. Status: Closed, November 14, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 20, 2024, the nearest before the penalty date.

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

11. May 302024

    Complaint investigation

    3 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 Jun 16, 2024
    • 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 Jun 16, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 16, 2024

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

12. Oct 102023

    Complaint investigation

    8 findings

    • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level FNo actual harm, potential for moreCorrected Nov 7, 2023
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Nov 7, 2023
    • 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 DNo actual harm, potential for moreCorrected Nov 7, 2023
    • 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 Nov 7, 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 Nov 7, 2023
    • 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 Nov 7, 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 Nov 7, 2023
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Nov 7, 2023

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

13. Mar 212023

    Standard health inspection

    22 findings

    • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level LImmediate jeopardyCorrected May 17, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jul 24, 2023
    • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Jun 13, 2023
    • 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 May 17, 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 May 17, 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 May 17, 2023
    • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected May 17, 2023
    • 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 May 17, 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 May 17, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 17, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 17, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 17, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 17, 2023
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 13, 2023
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 17, 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 DNo actual harm, potential for moreCorrected May 17, 2023
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jun 13, 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 May 17, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected May 17, 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 DNo actual harm, potential for moreCorrected May 17, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected May 17, 2023
    • F814Dispose of garbage and refuse properly.Level CPotential for minimal harmCorrected May 17, 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

   A Clean, Homelike Setting, Cited in Eight Inspections

   Inspectors cited F584 in March 2023, October 2023, May 2024, June 2024, October 2024, January 2025, May 2025 and September 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   23232424242425252525252526F584 across all 13 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in March 2023, October 2023, June 2024, July 2025, September 2025 and April 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.

   23232424242425252525252526F689 across all 13 inspections, oldest to newest
3. 3

   Reporting Suspected Abuse, Cited in Four Inspections

   Inspectors cited F609 in October 2023, July 2025, July 2025 and September 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.

   23232424242425252525252526F609 across all 13 inspections, oldest to newest
4. 4

   Quality of Care, Cited in Four Inspections

   Inspectors cited F684 in March 2023, May 2025, July 2025 and September 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.

   23232424242425252525252526F684 across all 13 inspections, oldest to newest
5. 5

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in May 2024, June 2024, May 2025 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.

   23232424242425252525252526F880 across all 13 inspections, oldest to newest
6. 6

   Grievances, Cited in Three Inspections

   Inspectors cited F585 in October 2023, January 2025 and September 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242425252525252526F585 across all 13 inspections, oldest to newest
7. 7

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in October 2024, July 2025 and April 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.

   23232424242425252525252526F600 across all 13 inspections, oldest to newest
8. 8

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in March 2023, June 2024 and September 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424242425252525252526F656 across all 13 inspections, oldest to newest
9. 9

   Nutrition and Hydration, Cited in Three Inspections

   Inspectors cited F692 in March 2023, June 2024 and July 2025. This citation covers whether residents get enough food and fluids to stay healthy. 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.

   23232424242425252525252526F692 across all 13 inspections, oldest to newest
10. 10

    Pharmacy Services, Cited in Three Inspections

    Inspectors cited F755 in March 2023, January 2025 and July 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. 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.

    23232424242425252525252526F755 across all 13 inspections, oldest to newest
11. 11

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in March 2023, June 2024 and September 2025. 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.

    23232424242425252525252526F761 across all 13 inspections, oldest to newest
12. 12

    Garbage and Refuse, Cited in Three Inspections

    Inspectors cited F814 in March 2023, June 2024 and October 2024. This citation covers whether garbage and refuse are disposed of properly. 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.

    23232424242425252525252526F814 across all 13 inspections, oldest to newest
13. 13

    Citation F925, Cited in Three Inspections

    Inspectors cited F925 in October 2023, October 2024 and September 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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.

    23232424242425252525252526F925 across all 13 inspections, oldest to newest
14. 14

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in June 2024 and July 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. 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.

    23232424242425252525252526F558 across all 13 inspections, oldest to newest
15. 15

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in July 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242425252525252526F610 across all 13 inspections, oldest to newest
16. 16

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in May 2025 and September 2025. This citation covers whether each resident’s assessment correctly records their condition. 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.

    23232424242425252525252526F641 across all 13 inspections, oldest to newest
17. 17

    The First 48 Hours, Cited in Two Inspections

    Inspectors cited F655 in May 2024 and May 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.

    23232424242425252525252526F655 across all 13 inspections, oldest to newest
18. 18

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in May 2025 and April 2026. 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.

    23232424242425252525252526F657 across all 13 inspections, oldest to newest
19. 19

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in March 2023 and September 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232424242425252525252526F677 across all 13 inspections, oldest to newest
20. 20

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in March 2023 and May 2025. This citation covers oxygen, breathing treatments and other respiratory care. 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.

    23232424242425252525252526F695 across all 13 inspections, oldest to newest
21. 21

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in March 2023 and September 2025. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 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.

    23232424242425252525252526F756 across all 13 inspections, oldest to newest
22. 22

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in March 2023 and January 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.

    23232424242425252525252526F759 across all 13 inspections, oldest to newest
23. 23

    Citation F801, Cited in Two Inspections

    Inspectors cited F801 in October 2023 and July 2025. The agency describes it this way: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. 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.

    23232424242425252525252526F801 across all 13 inspections, oldest to newest
24. 24

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in March 2023 and September 2025. 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.

    23232424242425252525252526F812 across all 13 inspections, oldest to newest
25. 25

    Provide training in compliance and ethics, Cited in Two Inspections

    Inspectors cited F946 in July 2025 and September 2025. The agency describes it this way: Provide training in compliance and ethics. 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.

    23232424242425252525252526F946 across all 13 inspections, oldest to newest
26. 26

    Citation F947, Cited in Two Inspections

    Inspectors cited F947 in July 2025 and September 2025. The agency describes it this way: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. 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.

    23232424242425252525252526F947 across all 13 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 was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in eight inspections, most seriously at level F.

2. 02

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

   Accident Hazards and Supervision: cited in six inspections, most seriously at level J.

3. 03

   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.

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 four inspections, most seriously at level J.

5. 05

   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 F.

6. 06

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

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

7. 07

   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.

8. 08

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

   Care Plans: cited in three inspections, most seriously at level E.

9. 09

   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 J.

10. 10

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

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

11. 11

    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.

12. 12

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in three inspections, most seriously at level F.

13. 13

    What changed after F925 was cited, and how do you check it now?

    Citation F925: cited in three inspections, most seriously at level F.

14. 14

    How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

    Needs and Preferences: cited in two inspections, most seriously at level D.

15. 15

    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 D.

16. 16

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

    Accurate Assessments: cited in two inspections, most seriously at level E.

17. 17

    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.

18. 18

    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 D.

19. 19

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

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

20. 20

    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 D.

21. 21

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level E.

22. 22

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

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

23. 23

    What changed after F801 was cited, and how do you check it now?

    Citation F801: cited in two inspections, most seriously at level F.

24. 24

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

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

25. 25

    What changed after F946 was cited, and how do you check it now?

    Provide training in compliance and ethics: cited in two inspections, most seriously at level F.

26. 26

    What changed after F947 was cited, and how do you check it now?

    Citation F947: cited in two inspections, most seriously at level F.

27. 27

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

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

28. 28

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

    A $424,350 civil money penalty was imposed May 29, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

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

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

  Wisconsin state survey agency

  Inspection Mar 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection Oct 10, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection May 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin 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)

  Wisconsin state survey agency

  Inspection Jul 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)

  Wisconsin state survey agency

  Inspection Oct 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection Jan 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection May 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection Jul 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection Jul 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

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

  Wisconsin state survey agency

  Inspection Jul 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)

  Wisconsin state survey agency

  Inspection Sep 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)

  Wisconsin state survey agency

  Inspection Apr 30, 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 · 525371

  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.