Belgrade Nursing Home
103 School Street, Belgrade, MN 56312 · Non profit - Corporation · 34 certified beds · (320) 254-8215 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (74%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 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 held steady at 5 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 | 26.5% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.1% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.1% | 1.9% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.8% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 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 | 3.7% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 20.0% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.2% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.9% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 34 beds and averages 25.4 residents a day — about 75% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.34 hrs/resident/day on weekends vs 4.68 on weekdays — 7% thinner on weekends. RN hours go from 0.87 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 74% is well above the national median of 45%.
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.
9 citations, most serious first — scroll within the box to see all.
- Potential for harm · Dcited before2026-05-28 · 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 while providing morning cares for 1 of 3 residents (R8) when observed. Findings include: R8's significant change Minimum Data Set, dated [DATE], indicated diagnosis of dementia. During an observation on 5/28/26 at 7:29 a.m., nursing assistant (NA)-A got clothing out that R8 wanted to wear. NA-A assisted R8 to the wheelchair and took R8 to the bathroom. NA-A put on clean gloves and took down R8's pants. R8 sat down on the toilet. NA-A put on clean underwear, pants and socks. NA-A gave R8 a wet cloth to wash the face and R8 dried the face. NA-A removed R8's soiled brief and took soiled gloves off. NA-A put on clean gloves on and removed R8's shirt and washed arm pits, dried them, put on R8's deodorant. NA-A took off the soiled gloves and put on R8's shirts. NA-A put on clean gloves and had R8 stand to wipe the bowel moment from R8's bottom. R8 sat down on toilet. NA-A removed her soiled gloves and put on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 survey results were provided to 1 of 1 residents (R4) upon request. Findings include: R4's quarterly Minimum Data Set, dated [DATE], identified intact cognition. During interview on 6/12/25 at 4:05 p.m., R4 stated she had requested the results from the last re-certification survey and said they tell me they don't have the results yet. R4 stated she had concerns about infection control practices as she had been sick three times this year already, and wanted to know the facility had been dinged for infection control. R4 said she had asked the activity director most recently at the resident council meeting the previous week. During interview on 6/12/25 at 4:32 p.m. the director of nursing stated the survey results were available and hanging on a bulletin board near the dining room. During observation on 6/12/25 at 4:35 p.m., the survey results posted on the bulletin board only contained the results of the recertification survey from…
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 · D2025-06-13 · 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 supervisor 1 of 3 residents (R1) at risk for elopement when R1 was able to leave the facility (remained on campus) without staff knowledge despite wearing a working wander guard device. Findings include: R1's admission Record indicated he admitted to the facility 9/11/20. Diagnosis included anxiety, unsteadiness on feet, history of falls and weakness. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he did not wander. The MDS indicated R1 required supervision to stand and ambulate and did not require the use of personal alarms. R1's facility Progress Notes indicated on 5/9/25, R1 was pleasantly confused, telling everyone he did not live at the facility and had just arrived the previous day. 5/11/25, The first time R1 went outside, nursing assistant (NA) was alerted he was outside the building. The NA said he was on his way back in so NA assisted him into the building. The second time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-20 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, and interview the facility failed to conduct and document a comprehensive facility-wide assessment which included all necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 22 residents in the facility. Findings include: Review of the facility's facility assessment on 2/19/25, showed it did not include the following requirements: 1) No input received or requested from the residents or resident families during the creation of the assessment. 2) No recruitment or retention plan for employees. 3) No contingency plan for staffing that does not evoke the emergency preparedness plan. On 2/19/25 at 5:15 p.m., the administrator confirmed they did not use or request input from residents or residents families to help create and complete their facility assessment. Furthermore, the administrator confirmed they did not have a recruitment and retention plan, or contingency staffing plan in place. A facility assessment policy was requested, and none was provided.
- Potential for harm · D2025-02-20 · 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 comprehensively assess and provide timely treatment of suspected urinary tract infection (UTI) for 1 of 1 residents (R20) who reported UTI symptoms and had repeated infections. Findings include: R20's quarterly minimum data set (MDS) dated [DATE], indicated R20 had a brief interview for mental status (BIMS) score of 15 indicating R20 was cognitively intact. R20 required substantial/maximal assistance with toileting including toilet transfers, incontinent of bladder but was not on a scheduled toileting program. R20's face sheet printed 2/20/25 indicated R20 had the following diagnoses of Type II Diabetes, high blood pressure, and a history of acute cystitis (a sudden inflammation of the bladder, commonly known as a urinary tract infection (UTI)), and history of UTI's. During interview on 2/18/25 at 12:57 p.m., R20 stated she had been having pain and burning when she urinated. R20 stated she had told facility staff 'over the weekend' but…
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 · D2025-02-20 · 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 identify indications (reason) for medications for 1 of 5 residents (R14) reviewed for unnecessary medications. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], included R14 had moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder. R14's order summary report dated 2/14/25, included amlodipine besylate (used to treat high blood pressure) 10 milligrams (mg) one tab by mouth every morning, lisinopril (used to treat high blood pressure) 10 mg one tab by mouth every morning, and psyllium (often used to treat constipation) 400 mg capsule give one by mouth at bedtime. All medication orders failed to include reason for use or associated diagnosis. During interview on 2/20/25 at 9:29 a.m., registered nurse (RN) case manager (CM)-A stated all orders were entered either by the case manager or a floor nurse with a new admission. Orders are then checked by two additional staff members. Orders…
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 · D2025-02-20 · 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 identify indications (reason) for medications for 1 of 5 residents (R14) reviewed for unnecessary psychotropic medications. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], included R14 had moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder. R14's order summary report dated 2/14/25, included deutetrabenazine 18 mg one tab by mouth every morning, risperidone 3 mg give one tablet by mouth two times a day, and trazodone 100 mg give one tablet by mouth at bedtime. All medication orders failed to include reason for use or associated diagnosis. During interview on 2/20/25 at 9:29 a.m., registered nurse (RN) case manager (CM)-A stated all orders were entered by the case manager or a floor nurse with a new admission. Orders are then checked by two additional staff members. Orders should have had an associated diagnosis or reason for use. The provider should have been updated 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 before2023-12-21 · 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
Based on observation, interview and record review, the facility failed to complete proper disinfection of multi-use equipment (pulse oximeter) was implemented to prevent the spread of infection for 4 of 4 residents (R3, R24, R27, R29). This had the potential to affect all 30 residents and staff. Findings include: On 12/20/23 at 7:26 a.m., trained medication aide (TMA)-A was observed placing pulse oximeter (blood oxygen level) on R24's finger and did not disinfect equipment following use. Continuous observation initiated. At 7:50 a.m., TMA-A was observed in process of placing un-sanitized equipment on R3's finger prior to surveyor interrupting process. TMA-A stated all shared equipment was cleaned with an alcohol disinfecting wipe between resident use. However, she had not sanitized the oximeter after using it on R24 and prior to R3. Disinfecting equipment was important to prevent spreading germs . On 12/20/23 at 7:59 a.m., TMA-B was observed placing pulse oximeter on R29's finger and did not disinfect equipment following use. Continuous observation initiated. At 8:22 a.m., TMA-B…
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 · D2023-12-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure restorative nursing care was provided for 2 of 2 residents (R28 & R9) reivewed for restorative care. Findings included: R28's Significant change Minimum Data Set (MDS) dated [DATE], indicated fully intact cognition (able to fully understand). Diagnoses of depression and displaced Tri-malleolar fracture of left lower leg (Broken Ankle). R28 walked in corridor once or twice and required one staff physical assistance. R28 needed assistive devices of a walker and wheelchair. Care Plan identified R28 had a restorative nursing walking program and was to be walked once daily with a front wheeled walker and wheelchair with the assistance on 1 staff and gait belt. R28 was to walk as far as tolerated. This intervention was to restore R28's activities of daily living (ADL). During observation on 12/19/23 at 12:16 p.m., R28 was seated in recliner with feet elevated, covered with blanket, and watching tv. No staff observed in room with R28.…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MONTENEGRO, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/01/2021 |
| LEMMER, JAMES | Individual | CORPORATE DIRECTOR | since 12/19/2006 |
| LIESER, TRUDY | Individual | CORPORATE DIRECTOR | since 11/24/2015 |
| WESTABY, SANDRA | Individual | CORPORATE DIRECTOR | since 11/26/2002 |
| WINGER, ANN | Individual | CORPORATE DIRECTOR | since 11/24/2015 |
| FISCHER, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2016 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $10K 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 245418. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, 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.