Anoka Rehabilitation And Living Center
3000 4th Avenue, Anoka, MN 55303 · Non profit - Corporation · 120 certified beds · (763) 528-6400 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,297 in federal fines (most recent 2024-03-26)
- its payroll-based staffing score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 4 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 | 11.7% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.5% | 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 | 1.9% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.9% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.0% | 20.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 9.0% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.6% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.6% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.1% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.6% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.3% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.06 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.18 | 1.90 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
60.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 390 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.5% 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 244 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 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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.
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 | 60.4%CMS range 56.6–65.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.6–12.8 | 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 | 63.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 99.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.6%CMS range 3.4–8.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 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 120 beds and averages 114.0 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.19 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.71 hrs/resident/day on weekends vs 4.27 on weekdays — 13% thinner on weekends. RN hours go from 1.34 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. 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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2024-03-26 · 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 Based on observation, interview, and record review the facility failed to ensure comprehensive assessments were consistently completed, provide and implement interventions to prevent recurrent pressure ulcers (PU) for 1 of 1 residents (R13) who had a history of facility acquired stage 3 pressure ulcers. The facility's failures resulted in actual harm when R13 developed a recurrent pressure ulcer to the right heel. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], indicated R13 was admitted to the facility on [DATE] with diagnoses including aphasia following intracranial hemorrhage (difficulty understanding or expressing speech following a brain bleed), morbid obesity, muscle weakness, heart failure, diabetes mellitus, non-Alzheimer's dementia, and arthritis. R13 required maximal assistance with mobility in bed and was dependent on staff for sitting up, lying down, and transfers. The MDS identified R13 as at risk of developing pressure ulcers/injuries with three current stage 3…
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 · D2025-11-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 identify, treat, monitor, and manage 1 of 3 residents (R1) reviewed for pain to the extent possible in accordance with R1's care plan, goals, and preferences. R1 stated pain and was observed having pain. R1 had available morphine sulfate every two hours as needed (PRN), which was not administered to him for his breakthrough pain. Findings include: Upon observation and interview on 11/12/25 at 9:54 a.m. R1 laying in his bed wearing a hospital gown. On his wall was a sign indicating for staff to be gentle and go slow with R1. R1 stated the care was bumpy, R1 referred to himself as an old, skinny man with soft skin. He stated it hurt every time he was moved. R1 stated he took Tylenol, a narcotic, and a steroid. R1 was not aware that he could ask for pain medication when he was having pain. Why didn't they tell me that? Upon observation on 11/12/25 at 10:58 a.m. nursing assistant (NA)-A entered R1's room to start his morning cares. NA-A…
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 before2025-08-21 · 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
Based on interview and document review the facility failed to ensure services were provided in a dignified manner to promote quality of life during incontinence care for 1 of 1 resident (R10) reviewed for dignity, Findings include:R10's face sheet printed 8/21/25, indicated R10 was admitted to the facility 3/12/25 and had the following diagnoses: hypertensive heart disease, chronic obstructive pulmonary disease, monoplegia of upper limb following cerebral vascular infarct (loss of voluntary muscle movement related to a stroke), adjustment disorder with depressed mood, pain and need for assistance with personal cares.R10's care plan with last completion date of 8/6/25, indicated a need for activities of daily living (ADL's) assistance with interventions to include assistance with placement of bedpan and extensive staff assistance with personal hygiene and grooming. The care plan identified R10 triggered for altered elimination with interventions to include assistance with placement of urinal, assist with perineal hygiene after toileting, and change incontinent briefs as needed.During…
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 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 record review the facility failed to ensure a psychotropic medication ordered as needed (PRN) was limited to 14-days or extended to a specific date with supporting rationale provided by the medical provider for 1 of 2 residents (R2) reviewed for psychotropic medication use.Findings include:R2's quarterly review minimum data set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, required assistance with activities of daily living (ADL's), and had the following diagnoses: Hypertension, Renal Insufficiency, Diabetes Mellitus, Hyperlipidemia, and Dementia. Review of R2's physician signed medication review dated 7/26/25, indicated the following order: Lorazepam Oral Tablet 0.5MG. Give 0.5MG by mouth every 4 hours as needed for anxiety, give PO/SL. The order had a start date of 7/9/25, but no end date noted. Review of monthly pharmacist recommendation and review dated 8/5/25 indicated the following: ' R2 has a PRN order for an anxiolytic, which has been in place greater than 14…
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 F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 record review the facility failed to maintain a complete, accurately documented and, readily accessible medical record in accordance with accepted professional standards of practice for 3 of 5 residents (R25, R9, R2) reviewed for advanced directives documentation. This deficient practice gave staff access to inaccurate information. Findings include: R25's quarterly minimum data set (MDS) dated [DATE] indicated R25 was admitted to the facility 9/29/21, had a BIMS of 15 indicating cognitively intact and had the following diagnoses, Diabetes, Hemiplegia (paralysis of one side of the body), and Multiple Sclerosis (an autoimmune disease that affects the spinal cord).Review of R25's electronic medical record (EMR) on 8/18/25, indicated the code status as DNR, and current orders indicated DNR. However, the Advance Directive link in R25's EMR revealed an outdated POLST which indicated FULL CODE. R9's re-admission MDS dated [DATE], indicated R9 was admitted to the facility on [DATE], had a BIMS of…
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 before2025-01-22 · 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 ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for for 2 of 2 residents (R8, R9) observed for COVID-19 transmission based precautions (TBP) and for 1 of 2 residents (R10) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice had the potential to affect all 112 residents who resided in the facility. Findings Include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing hygiene,…
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 before2025-01-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to maintain proper holding food temperatures for 18 of 19 residents observed to receive the noon meal on the Reflections unit. Further, the facility failed to maintain the ice machine in a sanitary manner to prevent potential food-borne illness for 39 residents who currently received ice from the ice machine in the Transitional care unit and Cardiac care unit area, and 36 residents who currently received ice from the ice machine in the Riverbend and cornerstone unit area. Findings include: FOOD TEMPERATURE During an interview on 1/21/25 at 1:20 p.m., family member (FM)-A stated several times when she was at the facility visiting R1, the food was cold and R1 refused to eat the food. FM-A further stated she began bringing food in for R1 to ensure R1 had food to eat. During a continuous observation on 1/21/25 at 11:49 a.m., dietary aide( DA)-A entered the Reflections unit with a covered cart of food trays in a heated cart from the second floor…
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 · D2024-12-17 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 record review the facility failed to include a resident discharge summary that included a reconciliation of all pre-discharge medications with resident's post-discharge medication (both prescribed and over-the-counter) at discharge for seven of ten residents (R1, R2, R5, R6, R7, R9, and R12). R1 received R2's Mirtazapine (a medication to treat depression) at discharge. Findings include: According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised and issued 8/8/24: -Reconciliation of Medications: A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. R1's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of multiple fractures…
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 before2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 1 of 2 unit ice and water dispensers for resident use were maintained in a clean and sanitary manner on the Cornerstone unit kitchenette. In addition, the facility failed to ensure 1 of 2 unit refrigerators were maintained in a clean and sanitary manner. This had the potential to effect 60 residents served by the Cornerstone unit kitchenette. Findings include: On 10/2/24 at 12:43 p.m., family member (FM)-A stated in August of 2024, the family council had shared concerns with management regarding the condition of the Cornerstone unit ice and water dispenser. There was excessive build up of hard water residue on the dispenser, leaving the family members concerned that the residents were ingesting bacteria. On 10/2/24 at 4:10 p.m., FM-B stated she had concerns about debris in the ice and water dispenser on the Cornerstone unit that served her family member. She had approached management about this concern in August 2024. On 10/2/24 at 4:37 p.m., the Cornerstone unit ice and water dispenser was observed…
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 before2024-07-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 food was properly stored, labeled, dated, and failed to maintain a clean and sanitary kitchen to reduce and/or prevent the risk of food borne illness this practice had the potential to affect all 112 residents, staff and guests who consumed foods from the facility kitchen. Findings include: During initial kitchen tour on 7/15/24 at 11:26 a.m., with certified dietary manager (CDM) the following concerns were observed: - Three dietary staff were observed without hairnets as they placed plastic wrap over plates of cooked food. - A reach in refrigerator to the immediate left of the stove top contained the following items of concern: 1) An unsealed bag of shredded cabbage dated 7/8/24. 2) Two open unsealed undated bags of bagels of bagels. 3) A small metal dish containing an undated, unidentified liquid, partially covered with plastic wrap. 4) An undated plate containing 2 baked biscuits loosely covered with plastic wrap. - The metal shelving units across from the stove had unidentified dried food…
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 · E2024-07-18 · tag F0554 — patternAllow 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 residents were comprehensively assessed for self-administration of medications for 5 of 5 residents (R3, R14, R74, R36, and R95), reviewed and observed for self-administration of medications. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact, and required assistance/supervision with activities of daily living (ADL's). The self-administration of medications assessment completed on [DATE], indicated R3 did not wish to self-administer medications or to keep them bedside. During observation and interview on [DATE] at 4:13 p.m., a bottle of prescription fluticasone propionate (nasal spray) was sitting on over-bed table. A tube of prescription arthritis pain relieving cream was sitting on stand in front of television. R3 stated he used the nasal spray whenever he needed due to his nose being dry all the time. R3 also stated he applied the pain-relieving cream to his knees, hands,…
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 21 citations
- Potential for harm · E2024-07-18 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 complete care conferences for 5 of 7 residents (R14, R16, R24, R29 and R69) reviewed for care planning. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition. During interview on 7/15/24 at 5:37 p.m., R14 stated he could not remember having quarterly care conferences with the facility. R14 had MDS submissions completed on 12/3/23, 2/2/24 and 5/20/24. The medical record failed to include documentation of care conferences. R16's quarterly MDS dated [DATE], identified R16 had severe cognitive impairment. During interview on 7/15/24 at 2:14 p.m., family member (FM)-A stated care conferences are held every 6 months or so and does not recall the last care conference with the facility. R16 had MDS submissions completed on 11/17/23, 1/23/24, 4/16/24 and 7/9/24. The medical record failed to include documentation of care conferences. R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 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 · E2024-07-18 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 on interview and document review the facility failed to ensure 4 of 5 residents (R24, R56, R80, and R102) were offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R24' s annual Minimum Data Set (MDS) dated [DATE], indicated R24 was 79, moderately cognitively impaired and had the following diagnoses: atrial fibrillation (top…
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 · D2024-07-18 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 document review and interviews, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) was provided to 1 of 3 residents (R86) reviewed for beneficiary notification. Findings include: R86's part A discharge minimum data set (MDS) dated [DATE], indicated R86 was admitted to the facility on [DATE] and their Medicare part A coverage ended on 5/23/24. R86's progress notes dated 5/21/24, indicated R86 received a Medicare-A Non-Coverage (CMS-10123) form. The form indicated R86's current covered services would end on 5/23/24. Although R86 remained in the facility, R86's medical record lacked evidence R86 received the SNFABN-CMS-10055 form as required. On 7/18/24 at 1:20 p.m., registered nurse (RN)-C and RN-D confirmed no SNFABN-CMS-10055 form was provided, and it should have been. On 7/18/24 at 3:37 p.m., the administrator stated their expectation was the SNFABN-CMS-10055 form should have been provided to R86, and it was important to provide 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.
- Potential for harm · D2024-07-18 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview, and document review the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 2 residents (R106, R107) with the potential to affect all residents transferred to the hospital. Findings include: R106's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition with medical diagnoses of displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, anemia, hypertension, gastroesophageal reflux (GERD), chronic kidney disease stage 3, diabetes mellitus, hyperlipidemia, depression, insomnia, chronic pain, muscle weakness, and history of falls. R106's progress note dated 5/26/24, indicated resident went to the emergency room (ER) for evaluation of new concerns. It was also noted that a bed hold was signed and sent with R106 to the hospital, and her family was notified of the transfer. Resident returned to the facility and discharged to home from the facility…
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 before2024-07-18 · 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 complete neurological assessments following falls for 1 of 1 resident (R85) who had unwitnessed falls. Findings include: R85's significant change Minimum Data Set (MDS) dated [DATE], identified R85 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R85's diagnoses included progressive neurological condition, hypertension, BPH, renal failure, diabetes mellitus, non-Alzheimer's dementia, Parkinson's disease, depression, and repeated falls. R85's post incident review, dated 6/2/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/6/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/8/24, identified an unwitnessed fall.…
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 · D2024-07-18 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 coordination of dialysis care for 1 of 1 resident (R14) who required dialysis (treatment to filter blood when kidneys are no longer able). Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and independent with all activities of daily living (ADL)'s. R14's diagnoses included end stage renal disease, heart failure, hypertension, depression, dependent on renal dialysis, tremors, and personal history of traumatic brain injury. R25's provider order printed 7/18/24, indicated R14 left for dialysis treatments every Monday, Wednesday, and Friday. On 07/15/24 at 5:19 p.m., R14 stated the facility had never sent any paperwork with him when he went to dialysis appointments. On 07/18/24 at 9:41 a.m., licensed practical nurse (LPN)-A stated when a resident went to dialysis, a communication sheet was usually sent with them which included a weight and vital signs. LPN-A further stated the paperwork 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 · D2024-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited order for 2 of 2 residents (R74 and R85) reviewed for Hospice. Findings include: R74's admission Minimum Data Set (MDS) dated [DATE], identified R74 had moderate cognitive impairment and required partial to moderate assistance with all activities of daily living (ADL)'s. R74's diagnoses heart failure, hypertension, GERD, anxiety disorder, depression, asthma/COPD, and encounter for palliative care. R74's electronic health record (EHR) identified R74 had an order for Lorazepam 0.5 mg PRN every four hours as needed for anxiety. The care plan indicated the facility worked with resident, hospice, and staff to meet resident needs. R74's medication administration record (MAR) indicated lorazepam 0.5 mg every four hours as needed. This order was initiated on 6/14/24 and was open-ended. 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.
- Potential for harm · D2024-07-18 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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 interview and record review, the facility failed to assist in obtaining routine dental services for 1 of 1 resident (R56) reviewed for dental services. Findings include: R56's quarterly Minimum Data Set (MDS) dated [DATE], identified R56 was cognitively intact and could make her needs known. The admission MDS dated [DATE], indicated R56 required supervisor and verbal cues to complete oral care. R56 did not display any type of dental concerns. During interview on 7/15/24 at approximately 12:00 p.m., R56 stated they would be interested in seeing a dentist and could not recall facility staff offering a dental appointment since admission. R56 could not recall their last dental appointment. During follow up interview on 7/17/24 at 1:35 p.m., R56 stated their teeth did not hurt but would like to see a dentist. R56's care plan dated, 11/15/23, directed the staff to assist R56 with oral cares. The plan directed R56 to brush teeth, gums, end of tongue; observe for mouth pain, ulcers, sensitivity, loose teeth,…
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 before2024-07-18 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 ensure enhanced barrier precautions were used for 1 of 3 residents (36) reviewed for infection control. Findings include: R36's significant change Minimum Data Sheet (MDS) dated [DATE], identified her cognition was intact. R36's required partial assistance with dressing her upper body, substantial assistance with dressing her lower body and was dependent with transfers. R36's diagnosis list dated 7/18/24 listed the following diagnoses: surgical amputation, diabetes, osteomyelitis (infection of the bone), methicillin resistant staphylococcus aureus infection (MRSA-type of bacteria that is highly resistant to antibiotics), a colostomy (opening in the abdomen to expel feces) and chronic ulcers (skin breakdown). R36's care plan dated 5/14/24, indicated R36 has a diagnosis of mulit-drug resistant organism (MDRO) and met the criteria for enhanced barrier precautions. Care plan interventions included to don gown and gloves during high contact…
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 before2024-04-22 · 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 Based on observation, interview and document review, the facility failed to ensure assessed and/or care-planned interventions for pressure ulcer care were implemented for 1 of 3 residents (R3) reviewed for heel pressure ulcers, who were at risk for additional, and/or worsened, pressure ulcers. Findings include: R3's significant change Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact, and he required substantial/maximal assistance with mobility. R3's diagnoses included Parkinson's Disease, diabetes, coronary artery disease, and age-related physical debility. The MDS identified R3 was at risk for pressure ulcers with an identified stage 3 pressure ulcer and an unstageable pressure ulcer with suspected deep tissue injury in evolution. R3 was provided pressure ulcer care. An Incident-Post Incident Review form, dated 3/19/24, identified the medical provider noticed a left heel ulcer that was open that day. Root cause of the ulcer appear[ed] to be a pressure sore. An Incident - IDT…
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 before2024-03-26 · 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 a dignified living experience was maintained for 2 of 3 residents (R1 and R13) reviewed for dignity. Findings include: R1's face sheet identified R1 had diagnoses including multiple sclerosis (MS), vascular dementia, and hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stoke) affecting right dominate side. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and required substantial/maximal assist to roll left and right and move from sitting to lying or lying to sitting. R1's care plan dated 9/26/19 identified R1 is at risk for ineffective coping related to diagnosis of MS, depression. R1 has noted behaviors of crying, tearfulness, sadness and is withdrawn at times. Likes to have her routine. She takes an antidepressant. R1 has expressed fear of covid and states she feels content in her room. The goal is for R1 to respond to redirection when tearful. Staff are…
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 · D2024-03-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 record review the facility failed to develop and implement the toileting care plan for 1 of 2 residents (R13) reviewed for toileting. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], indicated R13 was admitted to the facility on [DATE] with diagnoses including aphasia following intracranial hemorrhage (difficulty understanding or expressing speech following a brain bleed), muscle weakness, non-Alzheimer's dementia, depression, and arthritis. R13 required maximal assistance with mobility in bed and was dependent on staff for sitting up, lying down, transfers, and toileting hygiene. R13 was always incontinent of both bowel and bladder. R13's MDS dated [DATE], included the last Brief Interview for Mental Status (BIMS) completed, with a score of 3 indicating severe cognitive impairment. R13's Bowel and Bladder Data Collection assessment completed by nurse manager (NM)-B dated 1/20/24, identified R13 was always incontinent of urine, incontinence did…
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 before2024-03-26 · 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 observation, interview, and document review the facility failed to use mechanical standing lifts in accordance with manufacturer recommendations for 2 of 3 residents (R1, R13) reviewed for accidents. Additionally, failed to ensure the wander-guard system was operational to prevent elopement for 3 of 4 residents (R9, R14, R12) reviewed for elopement. Findings include: MECHANICAL LIFTS and COMMODE R1's face sheet identified R1 had diagnoses including multiple sclerosis (MS), vascular dementia, and hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stoke) affecting right dominate side. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and required substantial/maximal assist to roll left and right and move from sitting to lying or lying to sitting. R1's care plan dated 6/2/23, identified R1 had activity of daily living (ADL) self-care performance deficits due to MS with right sided weakness requiring extensive assist for most cares.R1…
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 before2023-05-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 foods stored in the refrigerator were labeled and dated when opened. These failures had the potential to affect all 109 residents in the facility who consumed food from the kitchen. Findings include: Observation of the walk-in refrigerator on 05/15/23 at 11:00 a.m., with the Assistant Dietary Manger in the main first floor kitchen revealed the following: -an open bag of onions that had been tied closed but sliced open, lacked a label with contents and opened on date. -an open bag of cheese, lacked a label with opened on date or use by date. -bag of sliced cucumbers, lacked a label with opened on date or use by date. -an open bag of cube ham, lacked a label with contents, opened on date or use by date. Observation continued to the walk-in freezer and revealed the following: -a bag of hashbrowns, lacked a label of contents and opened on or use by date. -French fries, lacked a label of contents and opened on or use by date. -wax beans, lacked a label of contents and opened on or use by date. -hot dogs,…
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 · D2023-05-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 observations, interviews, and record review, the facility failed to follow physician's orders for 2 of 2 Residents (R41 and R73) reviewed for nutrition. The facility failed to obtain and document weights for both residents according to the physician's orders. Findings include: R41's admission Record indicated admission on [DATE], and readmission date of 02/16/23. Diagnoses ncluded dementia, epilepsy, congestive heart failure, and adult failure to thrive. R41's quarterly Minimum Data Set (MDS) dated [DATE], revealed Brief Interview Mental Status (BIMS) score of 06 out of 15, cognitive impairment. R41's orders included obtain WEEKLY WEIGHT .every day shift every Saturday .Active 2/16/2023 06:00. R41's Care Plan dated 02/22/23 revealed, NUTRITION: Potential for altered nutrition status due to hospitalized for weakness, other dx (diagnosis): dementia, adult failure to thrive, CHF (congestive heart failure), GERD (gastroesophageal reflux disease). Food allergies. Decreased ability to communicate needs.…
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 · D2023-05-18 · 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, record review, and interviews, the facility failed to ensure two of two residents (Resident (R)53 and R73) who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene out of a total sample of 50 residents. Based on observation, interview and record review, the facility failed to provide necessary care for 2 of 2 residents (R53 and R73) reviewed for dependant for assistance with activities of daily living (ADL). Findings include: R53's admission Record indicated admission on [DATE] with diagnoses of congestive heart failure, type two diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and hospice services. R53's admission minimum Data Set (MDS) dated [DATE], indicated cognition intact. R53 required extensive assistance of two staff members for bed mobility and transfers, but extensive assistance of one staff for personal hygiene. R53's care plan updated 04/16/23 revealed, I am totally dependent…
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 · D2023-05-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observations, interviews, and record review, the facility failed to ensure respiratory equipment was maintained and stored appropriately for 1 of 1 residents (R53) reviewed for respiratory care. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: R53's face sheet indicated admission on [DATE] with diagnoses of congestive heart failure, chronic respiratory failure with hypoxia, atherosclerotic heart disease, pulmonary hypertension, chronic obstructive pulmonary disease, chronic kidney disease, and received hospice services. R53's admission Minimum Data Set (MDS) dated [DATE] indicated cognitively intact. R53's orders revealed Patient has pulse and/or is breathing. Comfort-Focused Treatments (Allow Natural Death) .Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort . R53's comprehensive care plan revealed I have a cardiac diagnosis requiring monitoring and medications/treatments: CHF (congestive heart failure),…
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 · D2023-05-18 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure staff had competency in skills and techniques necessary to care for residents. There were no continuing on-going education credits since 02/02/22 or competency evaluations available for review for 1 of 5 employees (registered nurse (RN-B)) reviewed for training competencies. Findings include: Review of RN-B's employee file and training record revealed that the last on-going continuing education credits were in 02/02/22 and four from 04/20/22. RN-B was given a formal email from the Human Resources department on 04/26/23 that stated You are receiving this email because you currently have overdue Relias Courses. We use Relias online learning to provide on-going education credits to our staff that require continuing education units and to prove regulatory compliance for education that is required by State or Federal governing agencies. Please log in and complete all overdue Relias courses no later than Wednesday, May 3rd. As of 05/18/23, Human Resources had not received any trainings from RN-B. Interview on 05/18/23 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.
- Potential for harm · D2023-05-18 · 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
Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled medications, for 1 of 4 nursing units. This failure prohibits the prompt identification of loss or potential diversion of controlled medications. Findings include: According to a Facility Related Incident (FRI) on 02/26/22 at 8:00 a.m., Licensed Practical Nurse (LPN-A) gave resident (R296) 0.5 milliliters (ml) of Dilaudid (Opioid that is used for treating pain). After giving the medication, LPN-A went to return the drug to the medication storage room but was called into another resident's room to assist with cares. At 6:30 p.m., the end of shift, LPN-A completed the medication count with the incoming nurse and then left for the day. The medication was missed on the count of drugs. In the early morning hours of 02/27/23, LPN-A went to remove her belongings out of her pockets and found the bottle of Dilaudid belonging to R296. LPN-A immediately called the facility and told the incoming nurse that she had taken the bottle home with her…
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 · D2023-05-18 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of 14 errors were made during medication administration for 2 of 5 residents (R40 and R77) observed for medication administration. The facility's medication error rate was 56%. Findings include: Observation on 05/16/23 at 7:50 a.m., Registered Nurse (RN-B) administered R40's medication. Per resident orders all medications may be crushed. The following medications were crushed together: Seroquel (antipsychotic to treat schizophrenia/bipolar disorder; sertraline (treat depression, anxiety, and panic disorder); empagliflozin (treat diabetes); and isosorbide mononitrate (treat angina, a type of chest pain). RN-B dropped the sertraline on the floor, picked it up and then disposed of the drug in the sharp's container. He got out another sertraline and crushed all the medications together in the same packet. RN-B emptied the packet into a medicine cup and spilled some crushed medications on the countertop. He added two teaspoons of applesauce 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.
- No harm found · C2024-07-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on document review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 112 residents residing in the facility and their visitors who may wish to view the information. Findings include: During the review of the staff posting documentation from 6/3/24 through 7/18/24 the facility failed to provide evidence of staff postings for the following dates: 6/8/24, 6/9/24, 6/15/24, 6/16/24, 6/22/24, 6/23/24, 6/29/24, 6/30/24, 7/4/24 through 7/7/24, 7/13/24 and 7/14/24. On 7/18/24 at 1:11 p.m., the staffing manager (O)-D confirmed they had not been doing the staff posting on the weekends. On 7/18/24 at 3:37 p.m., the administrator stated they were unaware it had not been completed, and their expectation was it would be completed daily to ensure the information was available for residents or visitors who may like to see it. The Staffing Hours Posting Policy last revised 01/2015, indicated the facility will post daily at the beginning of each shift the facility-specific shift schedule for the 24-hour period.
“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
$24,297 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $24,297 — penalty dated 2024-03-26
- Medicare payment denial — starting 2024-04-27 for 5 days
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 VOLUNTEERS OF AMERICA SENIOR LIVING — 6 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 | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 4.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 5 homes this chain runs (chain average 3.2★, 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 |
|---|---|---|---|
| ARNOLD, PATTI | Individual | CORPORATE DIRECTOR | since 07/01/2016 |
| BLOOM, SHAWN | Individual | CORPORATE DIRECTOR | since 11/01/2012 |
| ERICKSON, KAREN | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| HACKETT, KAREN | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| KNAPP, KEITH | Individual | CORPORATE DIRECTOR | since 07/01/2016 |
| MULLEN, BETH | Individual | CORPORATE DIRECTOR | since 07/01/2020 |
| PERKINS, DERRICK | Individual | CORPORATE DIRECTOR | since 07/01/2019 |
| PETERSON, JEANNE | Individual | CORPORATE DIRECTOR | since 07/01/2017 |
| RASE, NANCY | Individual | CORPORATE DIRECTOR | since 07/01/2016 |
| SHERIDAN, PATRICK | Individual | CORPORATE DIRECTOR | since 07/01/2023 |
| VIGEE, VORIS | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| BUDZYNSKI, JOSEPH | Individual | CORPORATE OFFICER | since 04/02/2012 |
| GAVIN, NANCY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 11/01/2012 |
| KING, MICHAEL | Individual | CORPORATE OFFICER | since 11/01/2012 |
| NUTZ, FAITH | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 09/01/2018 |
| LEE, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/05/2025 |
| ROBINSON, ANN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2020 |
| SCHMITZ, ZACHARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/02/2024 |
| SOCZYNSKI, PAUL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2024 |
| VOLUNTEERS OF AMERICA NATIONAL SERVICES | Organization | ADP OF THE SNF | since 03/10/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 20 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.
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.
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 245205. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.