Good Samaritan Society - Blackduck
172 Summit Avenue West, Blackduck, MN 56630 · Non profit - Corporation · 30 certified beds · (218) 835-3410 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,205 in federal fines (most recent 2026-07-01)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 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 | 15.6% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.4% | 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 | 2.2% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 18.1% | 4.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.3% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 1.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 72.4% | 96.1% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.7% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 36.1% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.8% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 20.3% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 0.0% | 14.8% | 12.0% | check this* — see note marked star below the table |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 30 beds and averages 27.6 residents a day — about 92% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 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 3.73 hrs/resident/day on weekends vs 4.12 on weekdays — 10% thinner on weekends. RN hours go from 0.86 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as 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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2026-07-01 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview, and document review the facility failed to ensure mechanically altered diets were served as prescribed for 6 of 6 residents (R1, R2, R3, R4, R5, R7) with a physician ordered modified texture diet. This resulted in R1 receiving the incorrect diet, an unaltered piece of pizza, on 6/10/26. R1 required the Heimlich maneuver to dislodge the pizza from her throat. The immediate jeopardy (IJ) began on 6/10/26, at approximately 5:30 p.m., when facility staff served R1 the incorrect diet resulting in R1 needing the Heimlich maneuver performed to dislodge a piece of pizza from her throat. The IJ was identified on 7/1/26, the administrator was notified of the IJ on 7/1/26, at 3:15 p.m. The immediate jeopardy was removed on 6/11/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1 R1's admission Record indicated she was admitted to the facility 4/24/26. R1's diagnoses included hemiplegia/hemiparesis…
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 before2025-10-31 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect pressure ulcer staging for 1 of 3 residents (R1) reviewed with pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which indicated a stage III pressure…
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 · D2025-10-31 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a baseline care plan related to pressure ulcers was developed for 1 of 3 resident (R1) who admitted to the facility with a pressure ulcer and developed pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which…
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 before2025-10-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to perform ongoing and accurate assessment of pressure ulcers for 2 of 3 residents (R1,R3) who were at risk for pressure ulcer development. In addition, the facility failed to implement interventions to reduce the risk for new or worsening pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Nursing Admit Re-Admit Data Collection dated 10/16/25 at 4:33 p.m., indicated skilled services to include wound care. Skin integrity assessment indicated a dehisced (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing) scar on the left side of her abdomen, left buttock: crease area unstageable ulcer due to previous location and a scratch on her arm.R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure there was a comprehensive assessment and monitoring for prescribing a psychotropic medication for sleep for 1 of 6 (R26); and failed to provide evidence a gradual dose reduction (GDR) or a clinical justification of a psychotropic medication was completed for 1 of 6 residents (R26, R7) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had a moderate cognitive impairment and had diagnoses that included dementia. R26 used antidepressant medication daily. R26's Order Summary Report dated 1/28/25, identified Trazodone HCl oral tablet (an antidepressant primarily used to treat major depressive disorder. It works by increasing serotonin levels in the brain, which can help improve mood, appetite, and energy levels, as well as reduce anxiety and insomnia related to depression. Additionally, trazodone is sometimes prescribed as a sleep aide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 3 residents (R2) reviewed for pressure ulcers.Findings include:R2's quarterly Minimum Data Set, dated [DATE], identified R2 had moderate cognitive impairment. Diagnoses included dementia, renal insufficiency and anemia. R2 was at risk of pressure injury/ulcer and required substantial/maximal assistance for bed mobility and was dependent on staff for transfers.R2's Braden Scale for Predicting Pressure Sore Risk dated 5/28/25, identified R2 was at high risk for pressure injury/ulcer.R2's care plan revised 5/29/24, included interventions to check and reposition R2 frequently during the day, 12:00 a.m. and 4:00 a.m. at night; turn from Side to Side: R2 required substantial/max assist of 1 staff member for turning side to side in bed with use of bilateral grab bars on bed.- During a continuous observation on 8/20/25 at 7:18 a.m., R2 was lying in bed. R2's head of bed (HOB) 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 before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess and analyze a resident fall with major injury to identify specific hazards and/or risks and to develop targeted interventions to reduce the potential for falls for 1 of 1 resident (R27) reviewed for falls.Findings include:R27's resident event form dated 8/8/25 at 4:45 p.m., identified on 8/8/25 R27 was observed peddling himself with his feet in the hallway, became tangled up in a computer table and fell out of his wheelchair. The wheelchair then fell on top of the resident. No immediate intervention put into place and unknown if there was an injury. R27's progress notes dated 8/11/25 at 4:50 p.m., identified R27 had a fall on 8/8/25 with a hip fracture and was currently in the hospital after hip nailing. Anti-roll backs would be applied to resident's wheelchair. However, the note failed to identify a description or cause of R27's fall.R27's falls tool report dated 8/15/25, identified R27 was at risk for falls related to an actual fall 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 · D2025-08-20 · 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 document review, the facility failed to ensure a physician order for indwelling urinary catheter; and failed to ensure urinary catheter care was provided in a manner to prevent contamination and potential urinary tract infection (UTI) for 1 of 4 residents (R4) reviewed for urinary catheter. Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had a severe cognitive impairment and had diagnoses that included hematuria, neuromuscular bladder dysfunction (nerve damage that affects bladder control), reflux uropathy (the backward flow of urine from your bladder into your kidneys. Without treatment, the condition could lead to complications such as high blood pressure and chronic kidney disease.), type 2 diabetes, dementia and a methicillin resistant staphylococcus aureus (MRSA). R4 used an indwelling urinary catheter.R4's care plan revised 4/18/25, identified R4 had an indwelling catheter due to urinary retention and obstruction. Staff were instructed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were addressed and acted upon and documented in the medical record for 2 of 5 residents (R26, R7) reviewed for unnecessary medications.Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had a moderate cognitive impairment and had diagnoses that included dementia. R26 used antidepressant medication daily. R26's Order Summary Report dated 8/21/25, identified Trazodone HCl oral tablet (an antidepressant primarily used to treat major depressive disorder. It works by increasing serotonin levels in the brain, which can help improve mood, appetite, and energy levels, as well as reduce anxiety and insomnia related to depression. Additionally, trazodone is sometimes prescribed as a sleep aide due to its sedative effects, and it is considered non-addictive.) give 25 milligrams (mg) at bedtime related to unspecified dementia, moderate, with other behavioral disturbance 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 · F2024-06-13 · 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 maintain clean and sanitary conditions in the dry storage of the kitchen. This practice had the potential to affect all 29 residents residing in the facility. Findings include: During the initial tour on 6/11/24 at 10:53 a.m., the dry storage was toured. There was dented can of tomato juice on the shelf for use. There were two large covered plastic bins. The first contained an opened 50 pound (lb) bag of cake mix with a bunched up, gaping top. The bin cover remained open to air. The second bin's cover was lying on a rack shelf and there were two 50 lb opened bags in the bin. The tops of the bags were bunched up and gaping open. The opened bag of biscuit mix had no date to determine when the bag had been opened and the opened bag of sweet cornbread mix was dated as opened 2/15/24. [NAME] (C)-A stated that was how they always were. C-A had no idea how long they were good for, how often they were used and/or if the cover should be on. C-A did not know who was responsible for the dry storage area and the kitchen…
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 · F2024-06-13 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities and develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware of that had the potential to adversely affect all 29 residents residing in the facility. Findings include: See also 880: the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissable organisms. Additionally, the facility failed to implement timely transmission-based precautions (TBP) and testing for COVID-19 according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. See also 882: the facility infection preventionist (IP) failed 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.
Show the remaining 12 citations
- Potential for harm · F2024-06-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. Findings include: The Monthly Infection Summary February 2024, identified resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance criteria met. However, the log failed to identify any resident not treated with an anitmicrobial (an agent that kills microorganisms (microbicide) 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 · F2024-06-13 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure there was a qualified infection preventionist (IP) to adequately assess, develop, implement, monitor, and maintain the infection prevention and control program. This had the potential to affect all 29 residents residing in the facility including staff and visitors. Findings include: See also F880: Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. During a phone interview on 6/13/24 at 8:39 a.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of a facility-initiated transfer for 1 of 1 resident (R14) reviewed for hospitalization. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R14's progress notes identified the following: - R14 was admitted to the hospital on [DATE], and returned to the facility on 3/6/24. The facility lacked any evidence identifying the OOLTC was notified of the transfer. - R14 was admitted to the hospital on [DATE], and returned to the facility on 3/26/24. The facility lacked any evidence identifying the OOLTC was notified of the transfer. During an interview on 6/13/24 at 11:25 a.m., the business office coordinator (BOC) stated when residents were transferred, she was in charge of getting bed hold form in resident's chart. The BOC was unaware if they had to notify the OOLTC when a resident was transferred. If it was their job, they were not told and had…
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 · D2024-06-13 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide the resident/responsible party a written bed hold policy at the time of hospital transfer for 1 of 1 resident (R14) reviewed for hospitalization. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R14's progress notes identified the following: - 3/21/24 at 6:43 a.m., R14 was hospitalized - 3/21/24 at 8:02 a.m., R14's family was notified resident was admitted to the hospital. The progress note does not address a bed hold. - 3/26/24 at 1:53 p.m., R14 returned to facility following hospitalization. During an interview on 6/11/24 at 2:12 p.m., R14 stated she was hospitalized in March of this year but did not recall receiving a notice of bed hold. During an interview on 6/13/24 at 11:19 p.m., registered nurse (RN)-B stated it was the nurse's responsibility to inform resident/resident representative of the bed hold policy either in person or by phone when a transfer was being done. When it 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 before2024-02-07 · 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 follow care planned interventions to reduce the risk for falls for 1 of 3 residents reviewed during the survey. Findings include: R3's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated required partial to moderate assistance to stand and perform toilet transfers. R3's care plan 10/12/23, identified a self care exhibited by needing assistance with activities of daily living. The care plan directed staff to assist R3 from a sit to stand position using a gait belt placed just underneath her armpits. From standing to sitting the care plan directed staff to gently press between her shoulder blades to help avoid plops and directed the use of a gait belt under her armpits. A facility document titled Other, dated 1/26/24, indicated R3 had been lowered to the floor by staff. R3 was unable to describe what happened. Environmental factors indicated: not applicable, physiological factors indicated: not…
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 · E2023-08-10 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 provide a face to face provider evaluation for continued use of a as needed (PRN) psychotropic medication for 1 of 1 residents (R26) with a PRN psychotopic medication; and failed to ensure a gradual dose reduction occured as warrented for 1 of 4 residents (R10) reviewed with psychotopic medications. Findings include: R26's significant change Minimum Data Set (MDS) dated 6/8//23, identified R26 had a severe cognitive impairment and included diagnoses of Alzheimer's disease and dementia. R26's psychotropic drug use Care Area Assessment (CAA) dated 6/8/23, identified R26 used psychopharmacological medications related to dementia without behavioral disturbances. R26 would be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. R26's physician orders dated 5/19/23, included an order for Risperdal 0.25 miligram (mg)…
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 · D2023-08-10 · 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 medications were not stored at bedside for residents deemed unable to safely self administer medications for 1 of 1 residents (R10) observed to have medication in their room. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment. Diagnoses included dementia and Parkinson's disease. R10's Order Summary Report dated 8/10/23, included Deep Sea Nasal Spray Solution 0.65% two sprays in each nostril every two hours as needed for congestion. The physician orders lacked self administration of medication orders. R10's care plan revised 10/31/22, identified R10 was able to keep nasal spray at bedside. R10's Resident Self-Administration of Medications assessment dated [DATE], identified R10 was not able to safely administer medication independently. During observation on 8/7/23 at 9:04 a.m., R10 was seated in her room and a bottle of nasal spray on the bedside table next to R10.…
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 · D2023-08-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facilty failed to ensure a Minimum Data Set (MDS) was submitted timely for 1 of 1 resident (R180) reviewed for failure to submit the MDS. Findings include: R180's annual MDS dated [DATE], was completed and signed on 1/25/23. However, the MDS was not submitted until 8/7/23, after surveyor entrance. R180's quarterly MDS dated , was completed and signed on. However, the MDS was not submitted until 8/7/23. after surveyor entrance. During an interview on 8/10/23 at 9:59 a.m., registered nurse (RN)-A stated R18 had an annual MDS completed in Jaunary 2023. RN-A made a mistake, clicked the wrong button and it wasn't submitted in a timely manner. Additionally, R180 had a quarterly in March 2023 and, for some reason, RN-A made the same mistake and the MDS wasn't submitted timely manner. The Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.16, dated October 2018, identified an RAI must be completed…
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 · D2023-08-10 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide a recapitulation of stay for 1 of 1 residents (R28) reviewed for discharge. Findings included: R28's discharge Minimum Data Set (MDS) dated [DATE], identified R28 was admitted to the facility on [DATE], and was discharged on 5/24/23. R28's medical provider order dated 5/24/23, identified resident was to discharge to assisted living. R28's progress note dated 5/24/23, identified resident was discharged . During an interview on 8/10/23 at 12:38 p.m., the business office coordinator (BOC) stated there wasn't a discharge summary or recapitulation of stay for R28's discharge on [DATE]. She would expect there to be a recapitulation of stay for all residents who had discharged . An email received on 8/10/23 at 2:33 p.m., from registered nurse (RN)-A identified a discharge summary or recapitulation of stay was not found for the discharge on [DATE]. She wrote in her email If I didn't know any better, I would think she is still a resident . An email…
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 before2023-08-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and document review, the facility failed to ensure the facility followed up and act upon the consulting pharmacists identified and reported medication irregularities for 1 of 5 residents (R10); and the pharmacist failed to identify an irregularity for 1 of 5 residents (R26) Ireviewed for unnessary medications. Findings include: R10's quarterly minimum data set (MDS) 6/29/23, identified R10 had severe cognitive impairment and required assistance for activities of daily living (ADL). R10's diagnoses included anxiety, dementia, and age-related cognitive decline. The assessment identified R10 received antipsychotic and antidepressant medications during the assessment period. R10's Consultant Pharmacist's Medication Review (MMR) dated 10/7/22, identified the Centers for Medicare & Medicaid Services (CMS) required a trial dose reduction of psychotropic medications twice within the first year of therapy or admission to facility and yearly thereafter. The pharmacist recommended a detailed clinical rationale if a dose reduction was not appropriate. The medical record…
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 · D2023-08-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R179, R4) reviewed for immunizations. Findings included: R179 face sheet identified she was admitted on [DATE], and had a diagnosis of diabetes mellitus, type 2. R179's immunization record identified R179 historically received pneumococcal polysaccharide vaccine (PPSV23) on 3/8/01, and historically received the pneumococcal conjugated vaccine (PCV13) on 5/14/15. R179's medical record lacked any evidence R179 or R179's representative received education regarding pneumococcal vaccine booster and there was no indication R179 was offered the pneumococcal vaccine per CDC guidance. R4's face sheet identified she was admitted on [DATE], and had diagnoses of Parkinson's disease, and history of a pulmonary (lung) embolism (blood clot). R4's immunization record identified R4 historically received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-08-10 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 6 of 6 residents (R4, R11, R180, R5, R12, R14) reviewed for restraints; and 1 of 1 residents (R14) reviewed for catheter. Findings include: R4's quarterly MDS dated [DATE], identified R4 had severe cognitive impairment and used a bedrail as a restraint daily. R4's Physical Restraint Care Area Assessment (CAA) dated 12/28/22, identified R4's bedrail/grab bars were used for re-positioning and increased independence with bed mobility and did not function as restraints. R4's care plan dated 12/29/22, identified R4 had an activitivies of daily living (ADL) self care performance deficit related to a diagnosis of Parkinson's disease and R4 used a bedrail/grab bar for re-positioning and increased independence with bed mobility. R4's bedrail/grab bar did not function as a restraint. During an observation on 8/8/23 at 12:15 p.m., R4 had a grab bar attached to the side of her bed. During an interview 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.
“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
$22,205 in federal fines across 1 penalty.
- $22,205 — penalty dated 2026-07-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.0 | -2.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 2.8 | -1.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
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 |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 04/13/2026 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| BILLUPS, SHERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/14/2018 |
| BJERKE, BRANDON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/12/2021 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| SANDGREN, DEEANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2023 |
| DTN STAFFING INC | Organization | ADP OF THE SNF | — | since 08/02/2024 |
| FOCUSONE SOLUTIONS | Organization | ADP OF THE SNF | — | since 03/04/2024 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/13/2018 |
CMS files one row per role, so the 57 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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 $700K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245600. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-20, 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 →
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