Presbyterian Homes Of Arden Hills
3220 Lake Johanna Boulevard, Arden Hills, MN 55112 · Non profit - Corporation · 128 certified beds · (651) 631-6000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
- 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 (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.6% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.2% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.8% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.7% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.1% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.8% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 36.9% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.3% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.4% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.0% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.1% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 8.1% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.8% | 82.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 7.3% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 17.9% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.32 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.37 | 1.90 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.7% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.6% 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 38 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 0.28 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 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.7%CMS range 25.2–53.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.3–15.0 | 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 | 52.6% | 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 | 31.6% | 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 | 44.7% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 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 | 6.4% | 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 | 7.4%CMS range 3.7–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 128 beds and averages 124.8 residents a day — about 98% occupied, or roughly 3 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 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 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 3.84 hrs/resident/day on weekends vs 4.29 on weekdays — 11% thinner on weekends. RN hours go from 0.90 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 19% 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 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-06-06 · 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 ensure adequate supervision and scheduled toileting to reduce the risk for falls for 1 of 3 residents (R1) who had a history of falls. This resulted in actual harm for R1 who had an unwitnessed fall requiring emergency department (ED) services, sustained a laceration to the head, received five staples, and was admitted to the hospital for further observation. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of severely impaired cognition without behaviors and lower impairment of range of motion (ROM) on one side, repeated falls, hip fracture, weakness, and shortness of breath), Alzheimer's, and dementia. R1 required supervision/touching with oral and personal hygiene, frequently incontinent of bowel and bladder, and verbal cues or touching/steadying with ambulation up to 150…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-29 · 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 interview and document review the facility failed to review and revise a care plan for 1 of 3 residents (R1) whose care plan was reviewed for revisions.Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, dependent on staff for transfers from surface to surface, and had diagnoses included dementia. R1's care plan dated 1/23/26, indicated R1's family member (FM)-A gave verbal permission for R1 to continue to use the stand aid lift as long as the resident was able to do so and understood the risk of bruising and skin tears R1 may receive. R1's Resident Transfer assessment dated [DATE], indicated R1 was full weight bearing, was able to stand for 8 (eight) seconds safely while holding onto an assistive device, and was cooperative during transfers. The recommended mechanism for transfers from surface to surface was a two-person transfer with the stand assist lift. R1's progress note dated 6/11/26 at 10:40 a.m., indicated R1 may no longer be…
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 · D2025-05-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with the resident's physician for a need to alter treatment significantly for one of one resident (R1) reviewed. This practice resulted in a delay of treatment to R1's pressure ulcers. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified atrial fibrillation. R1's additional diagnoses included chronic kidney disease stage 3 and spinal stenosis, sarcoidosis of other sites. R1's progress note dated 4/22/25 at 9:40 a.m. indicated medical director (MD)-A reviewed R1's sacral ulcer. Progress note indicated the pressure ulcer was red that extended out from the wound under four centimeters with moderate odor and drainage on the dressing. The progress note indicated the facility staff, or the MD would be calling nurse practitioner (NP)-A to arrange wound clinic visit or hospitalization for debridement soon. R1's progress note dated 4/22/25 at 9:49 a.m. indicated R1 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 · Dcited before2025-04-16 · 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 use proper personal protective equipment (PPE) who are on enhanced barrier precautions (EBPs) for 1 of 3 (R1) residents reviewed for falls. Findings include: R1's Face Sheet dated 1/1/19, indicated R1 had retention of urine. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, had an indwelling catheter, and needed extensive assistance with all cares. R1's care plan dated 3/31/35, indicated R1 was on enhanced barrier precautions (EBPs) because R1 had an indwelling medical device the plan directed staff to wear gown and gloves during high-contact resident care activities. Enhanced Barrier Precautions signage on R1's door undated, indicated providers and staff would wear gloves and gown for the following High-Contact Resident Care Activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toilet use, and when caring for wounds or…
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 before2024-09-12 · 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 ensure food was properly disposed of after their best by dates in 2 of 4 serving kitchens and failed to ensure food was properly stored in 2 of 4 of the serving kitchens reviewed. This had the potential to impact residents who reside on the unit the serving kitchen is located. Findings include: An observation on 9/9/24 at 1:21 p.m., the 3rd floor serving kitchen was reviewed. Server (S)-A was in the serving kitchen cleaning up after lunch. In the cupboard was a box containing 2 individual packets of instant cream of wheat. The top of the box was torn off. There was no use by date on the box. A second un-opened box of cream of wheat was next to the open box. The top of the box included best if used by date of 4/18/24. An interview on 9/9/24 at 1:30, S-A verified there was no best by date on the opened box of cream of wheat and the April date on the unopened box. S-A further stated lead server (LS) who was responsible for checking the dates…
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 before2024-09-12 · tag F0880 — failed to prevent and control infections — patternProvide 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 record review, the facility failed to ensure appropriate transmission-based precautions (TBP) were used for 3 of 3 residents (R69, R108, R4) who had COVID-19. Furthermore, the facility failed to ensure proper hand hygiene was used for 1 of 1 residents (R72) observed during personal care. Findings include: R69 significant change Minimum Data Set (MDS) dated [DATE], indicated R69 had severe cognitive impairment and diagnoses of dementia. R69's MDS further indicated R69 was dependent on staff for eating. R69's nursing progress note dated 9/1/24 at 5:07 p.m., indicated R69 had tested positive for COVID-19. R69's nursing order dated 9/1/24, indicated R69 required TBP because of an active infection of a highly transmissible pathogen that had been acquired by physical contact, airborne or droplet transmission. Staff were to assist resident to maintain strict isolation. R108's quarterly MDS dated [DATE], indicated R108 was cognitively intact and had diagnoses of cancer of the spine…
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 · D2024-09-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report to the state agency (SA) allegations of potential neglect and verbal abuse for 2 of 3 residents (R30, R37). Findings include: R30's Optional State Assessment (OSA) dated 7/18/24, indicated R30 rarely made self understood, did not have behaviors or reject cares, required extensive assistance for all activities of daily living (ADLs), had aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia or hemiparesis (paralysis or weakness on one side of the body). R30's annual Minimum Data Set (MDS) dated [DATE], indicated R30 had both a long-term and short-term memory problem, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers. R30's care plan dated 8/2/24, indicated R30 had an ADL self-care performance deficit and interventions included, R30 required two staff participation to dress, one staff person assist with personal hygiene, and one assist with eating. R30's care plan 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.
- Potential for harm · D2024-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure R30 received a pillow for positioning for prevention of pressure ulcers and that aided in comfort associate with contractures. Findings include: R30's annual MDS dated [DATE], indicated R30 had severely impaired cognitive skills for daily decision making, had an impairment in range of motion to both upper and lower extremities, was dependent on staff for all activities of daily living, was at risk for pressure ulcers and had pressure relieving devices for the chair and bed. R30's Medical Diagnosis form indicated the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side, vascular dementia, contracture of the right and left hand, abnormal posture, and osteoarthritis of unspecified site, R30's care plan dated 8/2/24, indicated R30 had limited physical mobility related to impaired balance, range of motion, dementia, right and left hand contractures,…
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 · D2024-09-12 · 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 observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained per professional standards for 1 of 1 resident (R30). Findings include: R30's Optional State Assessment (OSA) Minimum Data Set (MDS) dated [DATE], indicated R30 required extensive assist with bed mobility, transfers, eating, and toileting. R30's annual MDS dated [DATE], indicated R30 had severely impaired cognitive skills for daily decision making, did not identify whether R30 utilized oxygen therapy. R30's Medical Diagnoses form indicated the following diagnoses: chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). R30's physician's orders indicated the following order: • 1/8/24, Ok to keep oxygen at 1 to 4 liters via nasal cannula (NC) to keep oxygen saturations greater than 88%, change tubing every week. R30's care plan revised 8/2/24, indicated R30 had chronic respiratory failure with hypoxia and R30's goal was to receive oxygen per physician's orders and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0699 — isolatedProvide 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 inteview and document review the facility failed to identify potential triggers and offer specialized services for 1 of 1 resident (R275) who had a history of trauma. Findings include: R275's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of major depressive and anxiety disorder. It further indicated R275 had a behavior of socially isolating herself, required substantial assistance with toileting and partial assistance with mobility. R275's Long Term Care (LTC) Psychosocial assessment dated [DATE], indicated R275 had a dignoses of major depressive disorder, anxiey, and had a history of trauma. It also indicated R75 had felt numb, detached from others, activities and/or surroundings as a result of that trauma. It lacked documentation that triggers were assessed to prevent re-traumatization. R275's Comprehensive Nursing Assessment Data Collection dated 8/22/24, indicated R275 preferred female caregiver only. It lacked documentation that triggers were assessed to…
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 · D2024-09-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide medication as ordered by the provider for 1 of 3 residents (R72) observed during medication administration. Findings include: R72's quarterly Minimum Data Set (MDS) dated [DATE], indicated R72 had cognitive impairment and diagnoses of dementia and delusional disorder. R72's provider order dated 1/9/24, indicated R72 required Seroquel (antipsychotic medication used to help treat delusional disorders) 25 milligrams (mg) daily at bedtime. R72's September medication administration record (MAR) indicated R72 did not receive the ordered Seroquel on 9/9/24 as the dose was not available. R72's nursing progress note dated 9/9/24 at 6:52 p.m., indicated R25's Seroquel was not available and follow up with pharmacy was needed. A facility form titled Refill Reorder Form dated 9/1/24, indicated R72's Seroquel was requested to be refilled. A facility form titled Refill Reorder Form dated 9/8/24, indicated R72's Seroquel was requested to be…
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 11 citations
- Potential for harm · D2024-09-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure medication errors were prevented for 2 of 4 residents (R72, R109) observed during medication administration. This resulted in a medication error rate of 7.69%. Findings include: R72 R72's quarterly Minimum Data Set (MDS) dated [DATE], indicated R72 had cognitive impairment and diagnoses of dementia and delusional disorder. R72's provider order dated 1/9/24, indicated R72 required Seroquel (antipsychotic medication used to help treat delusional disorders) 25 milligrams (mg) daily at bedtime. R72's September medication administration record (MAR) indicated R72 did not receive the ordered Seroquel on 9/9/24 as the dose was not available. R72's nursing progress note dated 9/9/24 at 6:52 p.m., indicated R25's Seroquel was not available and follow up with pharmacy was needed. An observation on 9/9/24 at 6:48 p.m., trained medication assistant (TMA)-A prepared to administer R72 medications. R72's Seroquel was not available for…
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 before2023-08-30 · 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 were labeled, free from freezer burn, and the freezers were cleaned and maintained. Additionally, the facility failed to ensure use of hair restraints during food preparation and the refrigerators in the unit dining rooms were maintained. Findings include: During the initial kitchen tour with the nutrition and culinary supervisor (NCS) on 8/27/23 at 11:51 a.m., observed the following: Kitchen Freezer: • 1 package of undated veggie burger patties NCS stated the patties would be tossed because they should have been dated • 1 full box dated 6/19/23, contained ground hamburger patties that were open to air NCS stated the package should be closed and verified there were ice particles on the hamburger and the meet contained varied colors. • Hot dogs in an undated plastic container, NCS stated she had no idea how long they had been in the freezer • 1 bag of undated and opened to air corn with a best by date of 7/2025 • 1 package of pork cutlets NCS stated contained ice particles and was freezer burnt…
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 · E2023-08-30 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide air bed monitoring for safety and function for 1 or 1 resident (R6), reviewed for air bed safety. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact, and required extensive assist of one staff for bed mobility and transfers. R6's face sheet printed 8/30/23, indicated resident diagnosis included congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), urinary tract infection, and atrial fibrillation (an abnormal heartbeat). R6's skin integrity care plan updated 7/28/23, indicated R6 had a pressure relieving mattress. R6's physician orders dated 8/8/23, indicated air mattress for skin integrity. During observation on 8/29/23 at 2:03 p.m., R6 air mattress control device had a continuos blinking red light. During interview on 8/29/23 at 2:28 p.m., engineer technician (ET)-B stated if an air bed 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 · D2023-08-30 · 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 document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R6, R8) reviewed for dignity. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had severe cognitive impairment, did not reject care and it was somewhat important to choose what clothes to wear, was totally dependent on staff for personal hygiene to include shaving. R8's diagnoses included: non traumatic brain dysfunction, unspecified dementia, diabetes mellitus, depression, and hemiplegia or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). R8's care plan dated 6/27/23, indicated R8 wanted to be clean and well dressed daily. Further, R8 wore a wig that was to be on in the a.m., and off at bedtime, and required two staff participation with personal hygiene and oral care. Additionally, R8 had physical behaviors of striking out, hitting and scratching staff during cares due to…
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 · D2023-08-30 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 2 of 2 residents (R25, R98) had been assessed to safely self-administer medications. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had mild cognitive impairment and diagnoses of stroke and chronic respiratory failure. Furthermore, R25's MDS indicated R25 required supplemental oxygen. R25's provider order dated 10/5/22, indicated R25 required Ipratropium-albuterol solution .5/2.5 milligrams (mg) per 3 milliters (ml) (medication to help open airways and improve breathing) via nebulizer (machine to administer inhaled medications) 4 times daily for shortness of breath. R25's provider orders lacked indication R25 was able to self-administer medications. R25's medical record lacked indication an assessment for R25 to self-administer nebulizer medications had been completed. An observation on 8/28/23 at 6:50 a.m., trained medication assistant (TMA)-A walked by R25's room stopped and opened the door…
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 · D2023-08-30 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide interpreter services for 1 of 1 resident (R98) with a preferred language of Cantonese reviewed for communication. Findings include: R98's annual Minimum Data Set (MDS) dated [DATE], lacked indication of R98's cognitive status, for brief interview of mental status (BIMS) with Care Area Assessment (CAA) triggered for cognitive loss, dementia and communication. R98's preferred language of Cantonese. R98's face sheet printed on 8/30/23, indicated R98 diagnosis included acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), acute onset chronic diastolic heart failure and hereditary (Heart failure that comes suddenly, often with sudden difficulty breathing and fatigue) and idiopathic neuropathy unspecified (a group of inherited disorders that affect the nerves that branch out from the brain and spinal cord).…
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 · D2023-08-30 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide privacy for 1 of 1 resident (R98), when a topical medication was administered. R98's annual Minimum Data Set (MDS) dated [DATE], lacked indication of a R98's cognitive status with Care Area Assessment (CAA) triggered for cognitive loss, dementia and communication. R98 required extensive assist of one staff for bed mobiity, and personal hygiene. R98's face sheet printed on 8/30/23, indicated R98 diagnosis included acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), acute onset chronic diastolic heart failure and hereditary (Heart failure that comes suddenly, often with sudden difficulty breathing and fatigue) and idiopathic neuropathy unspecified (a group of inherited disorders that affect the nerves that branch out from the brain and spinal cord). R98's physician orders dated 6/2/22, indicated…
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 · D2023-08-30 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to initiate a grievance process to address family member (FM) concerns pertaining to level of care changes for 1 of 2 residents (R5) reviewed for grievances. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 required extensive assistance for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. R5 did not ambulate in the hall or in room and had a diagnoses of non traumatic brain dysfunction, and Alzheimer's disease and received hospice care. R5's nursing progress note dated 8/22/23, indicated R5 was placed on COVID isolation from 8/1/23 to 8/10/23, due to testing positive for COVID and R5 was back to her baseline. R5's care conference summary progress note dated 8/24/23 at 6:54 a.m., indicated the household coordinator, clinical coordinator, hospice social worker (SW), R5's spouse, and R5's daughter attended the care conference and discussed R5's resource utilization group (RUG) (a system that…
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 · D2023-08-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 appropriate management of an indwelling catheter was provided for 2 of 2 resident (R31, R6) reviewed for indwelling catheters. Findings include: R31's significant change Minimum Data Set (MDS) dated [DATE], indicated R31 was cognitively intact and had diagnoses of liver disease, heart failure and urine retention. Furthermore, R31's MDS indicated R31 required an indwelling catheter. R31's bladder care area assessment (CAA) dated 7/13/23, indicated. R31 had an indwelling catheter and required monitoring to reduce risks of infection. R31's provider orders revised 9/19/22, directed staff to complete catheter cares each shift and as needed. R31's care plan dated 9/20/22, indicated R31 had an indwelling catheter related to urine retention. Furthermore, R31 required catheter care per facility protocol. An observation on 8/29/23 at 9:27 a.m., nursing assistant (NA)-A entered R31's room to assist with R31's catheter. R31 was sitting on 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 · D2023-08-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 monitor side effects for 1 of 3 (R43) residents reviewed for anticoagulation (blood thinner) therapy. Findings include: R20's quarterly MDS dated [DATE], indicated R20 had mild cognitive impairment and diagnoses of stroke with hemiplegia (paralysis on one side). Furthermore, R20's MDS indicated R20 was on an anticoagulation medication. R20's provider order dated 6/22/21, indicated R20 required rivaroxaban 20 milligrams (mg) daily for blood clots. A review of R20's body audits from 7/6/23-8/24/23 lacked indication R20 had any bruising. R20's care plan revised 7/23/23, indicated R20 was at risk for side effects of anticoagulation use for history of blood clots and stroke. Furthermore, R20's care plan directed staff to monitor for side effects including but not limited to bruising, bleeding, stroke, and heart attack. R20's nursing assistant (NA) task sheet titled Anticoagulant Use for 8/2023, indicated 8 times R20 had bruising, discoloration or bleeding…
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 before2023-08-30 · 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 hand hygiene was completed during catheter cares and catheter cares were provided to minimize risk of infection for2 of 2 residents (R31, R6) observed for indwelling catheters. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R20) observed for incontinent cares. Findings include: Catheter cares R31's significant change Minimum Data Set (MDS) dated [DATE], indicated R31 was cognitively intact and had diagnoses of liver disease, heart failure and urine retention. Furthermore, R31's MDS indicated R31 required an indwelling catheter. R31's bladder care area assessment (CAA) dated 7/13/23, indicated. R31 had an indwelling catheter and required monitoring to reduce risks of infection. R31's provider orders revised 9/19/22, directed staff to complete catheter cares each shift and as needed. R31's care plan dated 9/20/22, indicated R31 had an indwelling catheter related to urine retention.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 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 | 4.3 | -0.3 vs chain |
| Health inspection | 3 of 5 | 3.4 | -0.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 20 homes this chain runs (chain average 4.3★, 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 | Share | Since |
|---|---|---|---|---|
| PRESBYTERIAN HOMES AND SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2020 |
| BREMER BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 09/30/2011 |
| FLETCHER, JONATHAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| PEDERSON, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| MEYER, MARK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/1995 |
| PHS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2011 |
| LIPPERT, STACEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/18/2024 |
| MIELKE, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/29/2019 |
| PETERSON, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 19 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent 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
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 245424. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-12, 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.