Benedictine Care Community
201 9th Street West, Ada, MN 56510 · Non profit - Corporation · 49 certified beds · (218) 784-5500 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $154,460 in federal fines (most recent 2026-03-05)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.2% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.7% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.5% | 4.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.1% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.1% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.5% | 12.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.3% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.7% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.3% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.8% | 82.7% | 79.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.1%CMS range 30.7–58.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 6.5–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 49 beds and averages 40.9 residents a day — about 83% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.79 hrs/resident/day on weekends vs 3.31 on weekdays — 16% thinner on weekends. RN hours go from 0.91 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to identify and act on a change of condition for 1 of 3 residents (R1) who was care planned for potential infections, had a fever and was experiencing hallucinations which was an atypical symptom. This delay in treatment resulted in an immediate Jeopardy (IJ) for R1 when she was diagnosed with sepsis and was hospitalized . The IJ began on 2/21/26, when R1's vital signs indicated a temperature of 101.7 degrees Fahrenheit (F) and she was demonstrating other signs of illness such as vomiting, visible shaking, hallucinations, disruptive behavior, reports of pain, and crying with no nursing assessment conducted and the provider was not contacted. R1's symptoms continued until she was brought to the emergency department (ED), had a temperature of 102.8 degrees F, a physical appearance described as ill and toxic appearing and was diagnosed with septic shock and had to be hospitalized . The administrator was notified of the immediate jeopardy at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-09-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R1) received necessary medical attention following a change in a left hip surgical incision. Additionally, the facility failed to comprehensively assess, monitor, and document skin changes. R1 sustained actual harm and required hospitalization, surgery, and insertion of a peripherally inserted central line catheter (PICC) for intravenous (IV) antibiotic treatment for sepsis. Findings include: R1's hospital Discharge summary dated [DATE], identified mechanical ground level fall after losing her balance and sustained a left subtrochanteric femur fracture. She required surgery that included an surgical open reduction and internal fixation (ORIF) of the left hip and tramedullary nailing of left femur. Surgical incision noted to left hip with dressing. R1's progress notes from 8/25/25 through 9/10/25, identified: -8/25/25 at 2:57 p.m. Weekly Skin Check: R1 continued with stapes to surgical incision on the left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-10 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide sufficient nursing staff to meet residents' assessed needs and provide required care and services. The facility's staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents (R23, R24) reviewed in the sample requiring staff assistance with quality-of-care needs. The facility's ongoing staffing shortages had the potential to affect all 36 residents residing in the facility. Findings include:The Centers for Medicare and Medicaid Services (CMS) PBJ Staffing Data Report CASPER Report 1705 D identified the following:FY [fiscal year] Quarter 3 2025 (April 1 - June 30) identified the metric for excessively low weekend staffing was triggered. The trigger is defined as submitted staffing data that was excessively low.FY Quarter 4 2025 (July1 -September 30) identified the metric for excessively low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to establish and maintain an infection prevention and control program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, the facility failed to timely initiate and consistently implement transmission-based precautions for 2 of 2 residents (R12. R24) reviewed who exhibited signs and symptoms of potentially infectious diarrhea; failed to consistently identify and monitor residents exhibiting signs and symptoms of potential infection through the facility's surveillance system for 2 of 2 residents (R7, R24) reviewed for infection surveillance; failed to ensure staff adhered to infection prevention practices related to hand hygiene for 1 of 3 residents (R24) reviewed for activities of daily living; and failed to implement enhanced barrier precautions for 2 of 5 residents (R6, R7) reviewed who met criteria for enhanced barrier precautions. These…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to develop comprehensive, person-centered care plan to include enhanced barrier precautions (EBP) for 3 of 5 residents (R6, R7, R1) reviewed who were identified to be on EBP.Findings include: R6 R6's annual Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and required moderate assistance with bathing. R6 had an abdominal feeding tube (G-tube). Diagnoses included Parkinson's disease, narcolepsy, anxiety, and dysphagia (difficulty swallowing). R6's care plan with review date 6/1/26, identified R8 was frequently incontinent of bladder. Approaches included for staff to provide peri care two times per day and as needed (PRN) when incontinent. R8's care plan also identified R8 has special treatment/procedures related to the presence of a G-tube. Approaches included to provide daily care and observance of R8's G-tube to ensure patency and usefulness. The care plan failed to include instructions for EBP related to when staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dignified care was provided for 1 of 1 resident (R24) reviewed for dignity. Staff encouraged R24 to remain incontinent rather than assisting her to the toilet when requested, resulting in embarrassment, and loss of dignity. Findings include: R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder.R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was understood and usually understood. R24 denied shortness of breath. R24 stated she had pain per medication administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · tag F0585 — failed to handle grievances — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for 1 of 1 resident (R5) reviewed for grievances. Findings include: R5's Customer Concern/Grievance dated 5/20/26, identified family member (FM)-A reported R5's hearing aid was missing. The facility documented an initial search of the room, bedding, and laundry; however, no further investigation, follow-up, or resolution was documented. R5's progress notes from 5/20/26 through 6/6/26 contained no documentation regarding the missing hearing aid or grievance follow-up. During an interview on 6/9/26 at 2:33 p.m., the social services designee (SSD) acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated. During an interview on 6/9/26 at 3:48 p.m., FM-A reported she had not received any updates or information regarding the grievance after filing the concern. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to review and justify continued use of an as needed (PRN) psychotropic medication for 1 of 5 residents (R8) who were reviewed for unnecessary medications. Findings include: R8's quarterly Minimum Data Set, dated [DATE], identified R8 had moderate cognitive deficit and required moderate assistance with most activities of daily living (ADLs). R8 had not exhibited any behavior during the observation period and did not have hallucinations or delusions. R8 received antianxiety and antidepressant medications during the observation period. Diagnoses included congestive heart failure, dementia, diabetes, and depression. R8's undated Active Physician Orders, identified numerous medication orders for R8, which included haloperidol (antipsychotic) 1 milligram (MG) for agitation and restlessness every four hours PRN with start date 3/1/26 and end date was listed as open ended. R8's care plan dated 3/23/26, identified R8 was under hospice care for end-of-life status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide activities of daily living (ADL) care and services necessary to maintain residents' abilities by failing to provide timely toileting assistance for 1 of 6 residents (R24) reviewed who required staff assistance with toileting and transfers; and failed to provide timely supervision and assistance with eating for 1 of 6 residents (R23) reviewed who required staff assistance during meals. Findings include: R24: R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had mild cognitive impairment and was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder. Diagnoses included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and document review, the facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for 1 of 2 residents (R5) reviewed for pressure ulcers, creating the potential for contamination of pressure ulcer wounds and development of infection. Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact. R5 was substantial/maximal assist with transfers, and supervision with bed mobility. R5's diagnosis includes fracture of thoracic (mid back) vertebrae, muscle weakness, and amputation of right lower leg. It identified the resident was at risk for pressure ulcers but did not have one. R5's pressure ulcer/injury Care Area Assessment (CAA) dated 5/8/26, identified R5 was at risk for pressure ulcers due to recent injury with a fracture of thoracic vertebra. Plan of care updated for prevention of pressure related skin impairments. R5's provider's orders identified the following:6/1/26, identified for left heel,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure transfers were performed in accordance with assessed needs, care plan interventions, and facility policy for 1 of 3 residents (R24) reviewed for accidents. Staff performed transfers using a full-body mechanical lift with one staff member rather than the required two staff members, creating the potential for falls, entrapment, and transfer-related injury. Findings include:R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had a mild cognitive impairment and had diagnoses that included non-traumatic spinal cord dysfunction, diabetes, and dementia. R24 was dependent on staff for toileting and transfers and was frequently incontinent with bowel and bladder.R24's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 5/11/26, identified R24 was a recent admit from another care center and had diagnoses of dementia, depression, heart failure and asthma. R24 had clear speech and was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a reported medication error was investigated, documented, and addressed in accordance with facility policy for 1 of 5 residents (R37) reviewed for unnecessary medications. This deficient practice resulted in the facility's inability to determine the circumstances surrounding a reported Zepbound medication error, assess resident impact, and implement interventions to prevent recurrence.Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had a moderate cognitive impairment and had diagnoses that included morbid obesity, cerebral palsy and obstructive sleep apnea. R37's Event Report dated 4/23/26 at 9:37 a.m., identified Zepbound (an FDA-approved, once-weekly injectable medication containing tripeptide. It is prescribed alongside a reduced-calorie diet and increased exercise for chronic weight management in adults with obesity or those who are overweight with weight-related conditions) wrong dose on 4/22/26. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2026-06-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations regarding an irregularity in psychotropic medication use were addressed and resolved for 1 of 5 residents (R8) reviewed for unnecessary medications. The facility failed to ensure a required face-to-face practitioner evaluation occurred and allowed a PRN antipsychotic medication order to remain active and be administered despite repeated consultant pharmacist recommendations for review and discontinuation.Findings include: R8's quarterly Minimum Data Set, dated [DATE], identified R8 had moderate cognitive deficit and required moderate assistance with most activities of daily living (ADLs). R8 had not exhibited any behavior during the observation period and did not have hallucinations or delusions. R8 consumed antianxiety and antidepressant medications during the observation period. Diagnoses included congestive heart failure, dementia, diabetes, and depression. R8's care plan dated 3/23/26, identified R8…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-03-05 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and document review, the facility failed to ensure the infection preventionist (IP) completed the required training for the role of IP.Findings include: RN-B's record of completed training was reviewed and lacked evidence of training related to the role of IP. During interview on 3/5/26 at 2:22 p.m., registered nurse (RN)-B stated she was the facility designated IP. RN-B stated she had started the required training but had not had time to finish.Facility policy Infection Preventionist Role dated 8/2023, indicated the IP or designee is responsible for directing the infection prevention and control program within the facility. The IP should have a background and training appropriate for carrying out these responsibilities, have a primary professional training in nursing, medical technology, microbiology, epidemiology or other related field, be qualified by education, training, certification or experience, and have completed specialized training in infection prevention and control.
- Potential for harm · Dcited before2026-03-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure physician notification of a change of condition for 1 of 3 residents (R1) reviewed who subsequently admitted to the hospital for septic shock.Findings include:R1's Annual Minimum Data Set, dated [DATE], identified intact cognition and indicated she did not display hallucinations, delusions or behaviors.R1's care plan identified a self-care deficit and a potential for infection related to urinary incontinence. The care plan directed staff to update the provider as needed. The care plan indicated R1 was alert and oriented and independent in making decisions.R1's Vitals Report identified the following:2/21/26-10:32 a.m. temperature (Temp) 101.7 degrees Fahrenheit (F), pulse 140 beats per minute (bpm)-11:37 a.m. Temp 103.2 degrees F.-1:02 p.m. Temp 101.6 degrees F.-5:18 p.m. Temp 100.2 degrees F.2/22/26-9:50 a.m.- pulse (P) 109 bpm.-9:50 a.m. Temp 99.4 degrees F.-4:55p.m.- Temp 100.1 degrees F.2/23/26-8:50a.m. Temp 99.1 degrees F, P 102 bpm.-3:42…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure annual abuse training was completed for 2 of 10 staff reviewed for training.Findings Include:Nursing assistant (NA)-A had a hire date of 11/7/25. NA-A's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training.Registered nurse (RN)-B had a hire date of 8/28/24. RN-B's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training since 8/28/24.During interview on 3/5/26 at 1:41 p.m., the human resources manager (HRM) stated the mangers were responsible to ensure their staff completed training. The HRN said the corporate office sent messages quarterly regarding required trainings and she reminded the managers. The HRM said she did not track who had or had not completed required training.Facility policy Regulatory and Compliance Education dated 5/1/24, indicated each community should assign an associate the responsibility of the super registrar role. This person is to manage the tracking of the training system. Assigned hire courses should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure physician ordered medical supplies were available upon admission for 2 of 2 residents (R1, R2) reviewed who admitted to the facility with a catheter. In addition, the facility failed to obtain a physician's order prior to using an alternate catheter size.Findings include:R1's Resident Face Sheet indicated she admitted to the facility on [DATE]. R1's diagnosis included spinal cord injury, neuromuscular dysfunction of bladder and depression.R1's Physician Order Report dated 12/28/25 through 1/28/26, identified and order for catheter change every four weeks and as needed, dated 10/25/25. R1's care plan dated 9/23/25 identified a urinary catheter to manage obstructive uropathy.R1's Resident Progress Notes identified the following:-9/23/25, R1 requested a tub bath instead of a shower. No Foley catheter clamp available. Staff used tape to kink and clamp catheter.-9/25/25, When attempting to flush catheter, noted catheter was plugged. Spoke with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-25 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to promptly notify a physician of a change in condition for 1 of 3 residents (R1) reviewed when a left hip surgical incision showed signs of infection and required hospitalization. Findings include: R1's hospital Discharge summary dated [DATE], identified mechanical ground level fall after losing her balance and sustained a left subtrochanteric femur fracture. She required surgery that included an ORIF and tramedullary nailing of left femur. Surgical incision noted to left hip with dressing. R1's progress notes from 8/26/25 through 9/10/25, identified: -8/26/25 at 1:42 p.m. Skilled Nursing Documentation: Surgical wound left hip/thigh, no drainage, surrounding tissue intact and no pain. Nursing Interventions: surgical wound care. -8/26/25 at 8:33 p.m. Staples to left hip/thigh removed per order. R1 tolerated well. Cleansed area with saline and applied steri strips. -8/27/25, 8/28/25, 8/29/26, 8/30/25, Skilled Nursing Documentation completed. No…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-21 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were provided for 4 of 4 residents (R1, R2, R3, R4) who required assistance with bathing. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition and no behaviors. She had impaired range of motion (ROM) upper and lower extremities bilaterally and used a walker and wheelchair for mobility. She was dependent to roll left and right, sit to lying, lying to sit, sit to stand, and all transfers, and substantial/maximal assistance to walk 10 feet, personal/toilet hygiene, and upper/lower body dressing. Diagnoses included diabetes mellitus (DM), arthritis, and manic depression. R1's care plan dated 5/14/25, identified self-care deficit with bathing and personal hygiene. She would be clean and groomed. She required extensive assistance of one with bathing up to two times a week. R1's nursing assistant (NA) care sheet undated, bath day not identified. R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-21 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide restorative services for 4 of 4 residents (R1, R2, R3, R4) who discharge from Physical Therapy services with maintenance orders to maintain range of motion and conditioning. This had the potential to affect all 21 residents care planned for restorative therapy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition and no behaviors. She had impaired ROM upper and lower extremities bilaterally and used a walker and wheelchair for mobility. She was dependent to roll left and right, sit to lying, lying to sit, sit to stand, and all transfers, and substantial/maximal assistance to walk 10 feet, personal/toilet hygiene, and upper/lower body dressing. R1's care plan dated [DATE], identified activities of daily living (ADL) deficit and required restorative active range of motion (AROM): required passive range of motion (PROM) to left upper extremity three to six days a week. Staff were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to meet resident care requests timely and promote resident dignity for 4 of 4 residents (R1, R2, R4) when call lights were not answered timely.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition and no behaviors. She had impaired ROM (range of motion) upper and lower extremities bilaterally and used a walker and wheelchair for mobility. She was dependent to roll left and right, sit to lying, lying to sit, sit to stand, and all transfers, and substantial/maximal assistance to walk 10 feet, personal/toilet hygiene, and upper/lower body dressing. She was frequently incontinent of bladder and always continent of bowel. Diagnoses included diabetes mellitus (DM), arthritis, and manic depression. R1's care plan dated 5/14/25, identified self-care deficit related to hemiplegia (one sided weakness) due to cerebrovascular accident (CVA) (stroke) with activities of daily living (ADL). Goal: resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-09 · tag F0585 — failed to handle grievances — widespreadHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 5 of 5 residents (R1, R25, R35, R36 and R37) reviewed for grievances. This deficient practice had the potential to affect all 39 residents residing in the facility. Findings include: On 4/8/25 at 11:00 p.m., a resident council meeting was held with five residents: R1, R25, R35, R36, and R37. During the resident council meeting, all five residents indicated they were unaware of how to file a grievance form. During an observation on 4/8/25 at 11:35 p.m., the surveyor could not locate grievance forms throughout the facility. During an interview on 4/8/25 at 11:43 a.m., social worker (SW) stated grievance forms were located behind the nurses' station. SW stated if a resident wanted to file a grievance, they would have to go to the staff to ask for a form. During an interview on 4/8/25 at 11:57 a.m., administrator confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-09 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 39 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified excessively low weekend staffing. Review of agency staff timecards from the first quarter verified agency staff were not punching in, therefore agency staff hours were not being submitted to CMS. During an interview on 4/8/25 at 2:41 p.m., corporate submitter (CS) verified she was the one that submitted the PBJ reports for the facility. CS stated she was unaware the facility was triggering for excessive low weekend staffing on the PBJ report. (CS) stated when the agency staff failed to punch in for their shift,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R19) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 had severe cognitive impairment and had diagnosis which included Alzheimer's, diabetes mellitus (DM), and hypertension (elevated blood pressure). Indicated R19 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of R19's electronic health record (EHR) revealed a self administration of medications (SAM ) assessment had not been completed and R19 did not have an order for self administration of medications. R19's Physician Order report dated 1/23/25, and signed 3/25/25, directed staff to administer Ipratropium-albuterol inhalation solution DuoNeb (medication used to relax the muscles in the airways and increase air flow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 1 residents ( R12) reviewed for activities of daily living (ADL)'s. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment and had diagnoses which included dementia, diabetes mellitus (DM), and hypertension (elevated blood pressure). Identified R12 required one person physical assist from staff with personal hygiene. R12's current care plan revised 3/26/25, indicated R7 had deficits with ADL's related to dementia. Indicated R12 required staff assistance with personal hygiene and had a goal to be clean and well groomed. R12's annual comprehensive Care Area Assessment (CAA) dated 5/25/24, identified R12 required assistance with ADL's. Identified R7 had an activity intolerance related to weakness, physical limitations and dementia. R12's care sheet undated, identified R12 required staff assistance with grooming. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately medication use in the Minimum Data Set (MDS) for 1 of 1 resident (R12) reviewed for MDS accuracy. Findings include: R12's annual MDS dated [DATE], identified no cognitive impairment. Diagnosis included diabetes mellitus type 2 (DM 2) (A long-term condition in which the body has trouble controlling blood sugar) and identified R12 was receiving insulin 7 days a week during the look back period. R12's physician order report dated 2/7/24, identified R12 received Victoza (a non-insulin, injectable medicine that may improve blood sugar in adults with DM 2). R12 did not have insulin listed in the orders, including the look back period of the MDS. During an interview on 2/7/24 at 2:11 p.m., registered nurse (RN)-A stated RN-A completed the annual MDS for R12 dated 12/29/23. R12 had not received insulin and the MDS coded incorrectly. The facility's Comprehensive Assessment and Care Planning policy dated 7/2/18, identified the assessment must…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interview and document review, the facility failed to follow the most recent Centers for Disease Control (CDC) standards for offering and educating on pneumococcal vaccinations for 1 of 5 residents (R2) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 was [AGE] years old and had a diagnosis of Parkinson's disease. R2's undated, immunization record, identified R2 received the pneumococcal polysaccharide vaccine (PPSV23) on 2/14/17. The immunization record did not identify R2 had received the pneumococcal conjugate vaccines (PCV13) vaccine. R2's medical record did not include evidence R2 or R2's representative received education regarding pneumococcal vaccine booster. There was no evidence R2 was offered the pneumococcal vaccine(s) per CDC guidance, in conjuction with shared clinical decision making with their provider, after R2 turned 65 yeard of age. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-20 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide routine bathing/showering assistance for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for activities of daily living, and who were dependent on staff for assistance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and diagnoses of anxiety and depression. R1 displayed verbal behavioral symptoms directed toward others (screaming, threatening, and cursing) three out of seven days, and did not reject cares. R1 required substantial/maximal assistance with shower/bathing, upper and lower body dressing, personal hygiene, toileting, tub/shower transfers, and used walker and wheelchair for mobility. R1's care plan dated 12/6/23, identified R1 had a self-care deficit with ADLs and directed staff to provide required assistance of one with bathing up to two times a week. R1's progress notes from 10/21/23, through 12/20/23, identified: -10/27/23 at 12:18 p.m. at beauty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$154,460 in federal fines across 1 penalty.
- $154,460 — penalty dated 2026-03-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to BENEDICTINE HEALTH SYSTEM — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 3 of 5 | 4.0 | -1.0 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 22 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HVIDING, MORGAN | Individual | CONTRACTED MANAGING EMPLOYEE | since 07/25/2022 |
| LUITHLE, TIMOTHY | Individual | CONTRACTED MANAGING EMPLOYEE | since 01/01/2024 |
| ANDERSON, LISA | Individual | CORPORATE DIRECTOR | since 11/16/2023 |
| BEITZ, RACHEL | Individual | CORPORATE DIRECTOR | since 11/07/2019 |
| FISCHER, HALLIE | Individual | CORPORATE DIRECTOR | since 11/16/2023 |
| HACK, TAYLAR | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| HOLTEN, TANNER | Individual | CORPORATE DIRECTOR | since 09/01/2021 |
| KAPPES, COLLEEN | Individual | CORPORATE DIRECTOR | since 09/01/2021 |
| MYKLESETH, KAILEY | Individual | CORPORATE DIRECTOR | since 09/01/2021 |
| PALM, RYAN | Individual | CORPORATE DIRECTOR | since 11/07/2019 |
| RING, BRUCE | Individual | CORPORATE DIRECTOR | since 07/01/2016 |
| BERGIEN, TRICIA | Individual | CORPORATE OFFICER | since 11/16/2016 |
| RYMANOWSKI, KEVIN | Individual | CORPORATE OFFICER | since 01/01/2008 |
| BENEDICTINE HEALTH SYSTEM | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2008 |
| CARLEY, GERALD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/03/2018 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $512K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245502. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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