St Johns On Fountain Lake

Location & what’s nearby

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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

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.

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.

58.8% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 71 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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.

Staffing

How full it usually is: this home is certified for 84 beds and averages 76.9 residents a day — about 92% occupied, or roughly 7 beds typically open. It runs fairly full. 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 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 is at or above 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 4.02 hrs/resident/day on weekends vs 4.76 on weekdays — 16% thinner on weekends. RN hours go from 1.01 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below 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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · J2025-08-06 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 medications were administered according to physician orders for 1 of 3 residents (R1) reviewed for medication administration. The facility's failures resulted in a significant medication error and an Immediate Jeopardy (IJ) situation for R1 who did not receive an increased dose of Torsemide (treat fluid overload related to heart or kidney disease) ordered by the physician. R1 was admitted to the hospital cardiac intensive care unit (ICU) for worsening congestive heart failure where she remained at the time of the survey. The IJ began on 7/9/25 when staff failed to administer an increased dose of Torsemide as ordered, due to not following the rights of medication administration. This resulted in 11 incorrect doses between 7/9/25 and 7/16/25. The Administrator and Director of Nursing were notified of the IJ on 8/6/25 at 1:22 p.m. The facility implemented corrective action prior to the survey on 7/21/25 to prevent reoccurrence, so the IJ 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 safely use a full body mechanical lift per manufacturer's recommendations for 1 of 3 residents (R1) reviewed who used a mechanical lift. This resulted in harm when R1 fell from a full body mechanical lift causing ongoing pain in shoulders and neck region. In addition the facility failed to ensure comprehensive assessments were completed to determine proper sling size for 3 of 3 residents (R1, R2, and R3) who required transfers with a mechanical lift. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was alert and with diagnosis of quadriplegia, bilateral range of motion impairment to both upper and lower extremities. R1 was dependent with all activities of daily living (ADLs) except for eating, which required set up only and used a electric wheelchair independently. R1's Nursing Assessment for Total Mechanical lift dated 4/13/24 indicated R1 was deemed unsafe to use standing lift. The assessment directed staff to use…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 2 of 2 resident (R71, R68) who developed pressure ulcers. The facility failure resulted in R71 sustaining harm when the resident developed an unstageable pressure ulcer to left gluteus (butt cheek) along with three additional stage II pressure ulcers on gluteus. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.) Unstageable pressure ulcer: (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.) R71's Record of Admission, printed 1/10/24, indicated admission to the facility on [DATE], with diagnoses per the Diagnosis…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  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 dishwasher water temperatures in 3 of 3 neighborhood kitchens were monitored to ensure proper sanitization of dishes. In addition, the facility failed to ensure metal pans in the main kitchen were dry before storing. This had the potential to affect all 77 resident who resided in the facility. Findings include:During the initial kitchen tour on 12/1/2025 at 10:55 a.m., dietary director (DD)-C, was asked to lift several metal pans and metal bowls of various sizes - all of which were stacked upside down on a wire shelving unit. Observed one wet 9 X 13-inch pan and three wet extra-large stainless bowls. DD-C stated staff were supposed to set wet dishes on a wire rack in clean side of the dish room to completely dry before storing. DD-C stated it was important to ensure no bacteria grew on the pans used to prepare and cook resident food. DD-C stated staff were trained to dry dishes completely before storing and did not know why that had not been done. During an observation and interview on 12/1/25 at 1:36…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0554 — isolated
  Allow 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 1 of 1 resident (R19) who was observed to have medications in her room, had been appropriately assessed and deemed safe to self-administer medications.Findings include:R19's face sheet provided on 12/3/25, included diagnoses of fibromyalgia (chronic condition that involves widespread body pain), chronic pain syndrome, dry eye syndrome (chronic condition where eyes don't produce enough tears), irritable bowel syndrome (chronic disorder causing cramping, gas, constipation, diarrhea) with diarrhea, osteoporosis, bursitis (inflammation) of hips, and anxiety. R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R19 was independent with eating and oral care after set-up help. R19 required substantial assistance for mobility-related activities of daily living and did not walk.R19's physician orders that correlated to the over the counter (OTC)…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop 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 interview and document review, the facility failed to ensure the care plan included management of CPAP (continuous positive airway pressure) for 1 of 3 residents (R24) reviewed for respiratory care. In addition, the facility failed to ensure a care plan was initiated after a trauma assessment identified history of Post Traumatic Stress Disorder for 1 of 1 resident (R27) who was reviewed for mood and behavior. Findings include: R24's face sheet provided on 12/3/25, included diagnoses of obstructive sleep apnea and dementia. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, was understood and could usually understand. R24 was dependent upon staff for most all activities of daily living and did not walk. R24's orders dated 3/5/25, indicated okay to use home settings on his CPAP machine every shift. Orders dated 3/8/25, indicated CPAP cleaning wash mask, nasal pillows, tubing and headgear, wipe off. Flow generator every day shift every…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  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 individualized activities were provided for 1 of 2 residents (R80) reviewed for activities. Findings include:R80's face sheet printed 12/3/25, indicated diagnoses of chronic kidney disease, adjustment disorder with depressed mood and anxiety, hearing loss, muscle weakness, and palliative care.R80's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R80 had no behaviors or rejection of care, intact cognition, considered it very important to have books, newspapers, and magazines to read, important to keep up with current news, and not important to do things with groups of people.R80's care plan dated 10/14/25, indicated R80 was alert and oriented and able to make needs known, enjoyed all types of music, reading, classic television shows and war movies. R80's care planned activity interventions included all staff conversing with the resident while providing cares, ensure activities are compatible with known…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements and characteristics) were completed for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include:R1's face sheet received on 12/3/25, included diagnoses of pressure ulcer of sacral region, stage four (the most severe type, involving full-thickness tissue loss); diabetes, chronic kidney disease, hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscle weakness on one side of the body) following stroke.R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech; R1 was understood and could understand. R1 required substantial assistance with toileting and bed mobility; was occasionally incontinent of bowel and bladder. R1 didn't walk and used an electric scooter. R1 was at risk for a pressure ulcer and had one, unhealed, stage four pressure ulcer present upon admission. R1's Skin CAA (care area…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 assess safe smoking for 1 of 1 resident (R69) reviewed for smoking. In addition, the facility failed to provide a receptable for R69 to safely ash and dispose of cigarettes. Findings include:R69's face sheet provided on 12/3/25, included diagnoses of tobacco use and chronic obstructive pulmonary disease (a progressive lung disease that causes breathing difficulties).R69's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R69 was cognitively intact, had clear speech, could understand and be understood. R69 was independent with most activities of daily living and used a motorized wheelchair for mobility. R69's orders did not include smoking. R69's care plan dated 7/30/25, indicated R69 was a smoker, would not suffer injury from unsafe smoking practices. R69 would be instructed about smoking risks and hazards and facility policy on smoking including locations, times and safety concerns. Progress note dated 7/11/25, indicated R69 asked…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 1 resident (R8) reviewed for hydration and who was dependent upon staff for fluid intake, was offered water/fluids on a consistent basis.Findings include:R8's face sheet printed on 12/3/25, included diagnoses of Alzheimer's disease and severe dementia.R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, unclear speech, was usually understood, and sometimes was able to understand. R8 required substantial/maximal assistance with eating and drinking. R8 was dependent on staff for activities of daily living and did not walk. R8's orders dated 8/12/24, indicated regular diet, minced and moist texture, regular/thin consistency, required assist with all meals.R8's care plan dated 8/23/24, indicated R8 had the potential for hydration problems related to dementia and Alzheimer's disease.R8's Kardex (a quick reference tool used by nursing assistants summarizing essential resident cares)…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  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 staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with daily maintenance for 1 of 3 resident (R33) reviewed for respiratory care and treatments.Reviewed- LS-done Findings include: R33's face sheet received on 12/3/25, included diagnoses of epilepsy (seizures), cerebral infarction (stroke) and obstructive sleep apnea (breathing repeatedly stops or become significantly reduced during sleep often due to collapse of the upper airway). R33's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R33 had moderate cognitive impairment, and was dependent on staff for all activities of daily living. Special treatments included CPAP. R33's plan of care dated 10/28/25, included a sleep disturbance using a CPAP at baseline. Interventions included CPAP auto set at night pressure settings at auto set home settings. Wipe off mask, nasal pillows and tubing. CPAP cleaning included…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0699 — isolated
  Provide care or services that was trauma informed and/or culturally competent.
  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 comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R27), reviewed who was evaluated for mood and behavior. Findings include: R27's face sheet received 12/3/25, included diagnosis of dementia with other behavioral disturbance and agitation and repeated falls. R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 understands and is understood. A Brief Interview for Mental Status (BIMS) indicated a score of 5 indicating severe cognitive impairment. R27 had behaviors that included verbal behavioral symptoms directed towards others 1 to 3 days, but less than daily. R27 had rejection of care 4 to 6 days. R27 required substantial/maximal assistance with transfers, toileting, bed mobility and transfers. R27 was taking antipsychotic and antidepressant medication. R27's Care Area Assessment (CAA) for cognitive loss/dementia dated…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 comprehensively assess and monitor signs/symptoms of fluid overload and failed to implement interventions including notification of changes to the physician for 1 of 3 residents (R3) who had diagnosis of congestive heart failure (CHF) reviewed for change of condition. Findings include:R3's face sheet dated 8/6/25, identified diagnoses of chronic diastolic heart failure (a condition in which the heart does not pump as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic kidney disease (longstanding disease of the kidneys leading to failure).R3's significant change MDS dated [DATE], identified R3 was independent with transfers, had intact cognition, and received diuretic medication. R3's cardiac focus care plan dated 4/21/25, included the following interventions:-fluid restriction: 2000 milliliters (ml) within 24 hours.-give cardiac medications as ordered.-monitor…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$16,448 in federal fines across 1 penalty.

• $16,448 — penalty dated 2024-07-26

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.

Who owns this facility

CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners 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.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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, FY2023). 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