Friendship Village Of Bloomington
8130 Highwood Drive, Bloomington, MN 55438 · Non profit - Other · 66 certified beds · (952) 830-9400 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0610), cited May 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 $99,500 in federal fines (most recent 2024-05-02)
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.7% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.7% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.9% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 3.5% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.4% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.8% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 71.9% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.8% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.27 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 1.90 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.5%CMS range 40.5–53.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.2%CMS range 5.2–11.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 73.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.0–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.81 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 66 beds and averages 63.5 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 4.40 on weekdays — 19% thinner on weekends. RN hours go from 1.30 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · K2024-05-02 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 thoroughly investigate injuries of unknown origin for 4 of 4 residents (R46, R18, R57, and 30) who had bruises where the injury was not witnessed, the resident could not explain the injury and the bruises were suspicious. The facility's pattern of failure to investigate injuries of unknown origin constituted an immediate jeopardy (IJ) situation. The IJ began on 3/26/24, when R46 was identified with a 2.4 centimeter (cm) x 2.6 cm inner thigh bruise and continued 3/27/24 when R18 was identified with a 7 cm x 5 cm facial bruise, 4/2/24 when R30 was identified with a 10 cm calf bruise, and 4/11/24 when R57 was identified with a 5.5 cm x 4 cm wrist bruise. The facility's system failure to identify suspicious injuries and thoroughly investigate injuries of unknown origin resulted in unverified rationale and lacked implementation of corrective action to protect resident from further sustaining injuries. The administrator, director of nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff implemented appropriate infection prevention and control practices, including proper hand hygiene while feeding residents, maintaining a clean resident care environment when staff were observed standing on a resident's (R6) mattress, and ensuring resident care items were cleanable and disinfected for a resident (R1) who had pool noodles affixed with tape on their bed and windowsill. Findings include: During observation on 5/4/26 at 12:25 p.m. NA-C was assisting two residents with eating at the same time. NA-C stood up from assisting the residents, scratched his face, touched the counter, obtained straws, and pushed one resident's wheelchair closer to the table before returning to assist the residents with eating without performing hand hygiene. The NA-C placed a straw into unidentified Resident 1's drink and assisted Resident 1, who was seated in a Broda chair and appeared asleep, with drinking. NA-C then assisted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 timely completion of a required annual Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed (R7), which had the potential to result in inaccurate assessment data and/or improper care planning.Findings include:R7's most recent MDS assessment, a quarterly assessment dated [DATE], was reviewed. Based on the assessment schedule, an annual MDS assessment was required to be completed following the 12/2/25 quarterly assessment.R7's electronic medical record (EMR) and MDS assessments lacked evidence the required annual MDS assessment was completed within the federally required timeframe. During an interview on 5/5/26 at 12:28 PM, MDS Coordinator and RN-B, stated there was a report in the EMR system that was run monthly on the 15th to track upcoming MDS assessments. After generating the report, a schedule with due dates for nursing staff to gather data and identify ARDs was completed. RN-B further stated he was unsure how R7 fell through 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 · D2026-05-07 · 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 accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for BiPAP machine (noninvasive ventilatory device that helps patients breath by delivering two levels of air pressure: higher pressure during inhalation and lower pressure during exhalation).Findings include:R59's quarterly MDS assessment dated [DATE], identified R5 had intact cognition with no hallucinations or delusions. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator (to include BiPAP and CPAP in section G2 and G3 below) was not marked with a check mark to indicate use. Under section Z1: none of the above: was marked with a check.During an observation on 5/4/26 at 4:41 p.m., a BiPAP machine was observed sitting on R59's side table by her bed. There was a gallon of water next to the machine. R59 indicated staff assist with her with the machine at night.During a follow up interview on 5/6/26 at 8:16 a.m.,…
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 before2026-05-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 3 of 5 residents (R59, R3 and R12) reviewed for comprehensive care plan. Findings include: R12's significant change Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment and needed extensive to total assistance for all activities of daily living. The MDS indicated R12's preferences of books, newspapers, music, animals, news, being with groups of people, going outside, and attending religious services were all very important. R12's activity assessment dated [DATE], indicated R12 would prefer to spend leisure time both individually and in group activities and prioritize therapy, resting, or recovery over leisure activities. The assessment indicated R12 would like to participate in outings such as leisure drives/tours and restaurants. The assessment indicated R12 identified with the Lutheran church and was interested in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update the care plan with identified and personalized nonpharmacological pain interventions for 1 of 1 residents (R3) reviewed for pain, failed to update fall interventions for 1 of 2 residents (R5) reviewed for accidents, and failed to update transfer ability for 1 of 1 residents (R6) reviewed who was identified as high risk for falls. Findings include: R3 R3's admission MDS assessment dated [DATE], identified R3 had intact cognition with no hallucinations or delusions. Furthermore, the assessment identified R3 received scheduled pain medication, did not receive as needed pain medication and did not receive any non-medication interventions for pain. During an observation and interview on 5/4/26 at 12:19 p.m., R3 stated he suffered from a lot of pain. R3 stated he was seen by a pain doctor and took as needed (PRN) pain medication. R3 stated he wasn't sure if any nonpharmacological interventions were helpful for his pain. R3's care plan, printed 5/6/26,…
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 before2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to develop and/or implement a process to ensure coordination with hospice and ensure skin was accurately evaluated/monitored to promote healing and reduce the risk of complications (i.e., worsening) for 1 of 1 resident (R12) reviewed for skin alterations. In addition, the facility failed to ensure comprehensive monitoring was developed and completed for 1 of 1 residents (R9) reviewed with extensive, unilateral knee swelling.Findings include:Hospice Collaboration/Skin MonitoringR12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment and was diagnosed with arthritis, heart failure, and malnutrition. The MDS indicated R12 was receiving hospice services and was dependent/required maximal assistance from staff for activities of daily living (ADLs).R12's care plan dated 2/25/26, indicated R12 had potential for/actual impairment to skin integrity related to an open area on her coccyx, a skin tear on her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · 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 ensure staff were following fall risk interventions for 1 of 1 (R6) resident identified at risk for falls to prevent further falls. Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 with severe cognitive impairment, delusions, and behaviors directed at others. In addition, R6 had no impairment of upper and lower extremities, required partial to moderate assistance with personal care and dressing. R6's diagnoses include dementia with behavioral disturbances, anxiety, affective disorder (psychiatric condition that affects emotional state), diabetes, and hearing loss.R6's care plan (CP) with date initiated of 9/1/25, identified R6 as Risk for Falls. CP Intervention with date initiated of 1/23/2024 indicated, TRANSFER: The resident is independent for transferring. Also, a CP Intervention with date initiated on 6/30/24, indicated, IF RESIDENT requires a Hoyer Transfer: SLING SIZE IS YELLOW/MEDIUM.R6's Kardex…
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 before2026-05-07 · 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 interview and document review, the facility failed to ensure proper orders were obtained and adequate coordination in place to care for a resident with a suprapubic catheter for 1 of 1 residents (R3) reviewed who used a catheter.Findings include:R3's admission MDS assessment dated [DATE], identified R3 had intact cognition with no hallucinations or delusions. Furthermore, indicated R3 had an indwelling catheter.During an interview on 5/4/26 at 12:17 p.m., R3 stated that he had a catheter (foley catheter- a thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) prior to admission. R3 stated that since moving to facility, the catheter had been changed to a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen into the bladder to drain urine) due to the infections he had been getting. R3 verified staff assist with the catheter.R3's care plan, printed 5/6/26, indicated the following:-(R3) is incontinent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate orders, accurate and complete respiratory care documentation and resident-specific ordered settings for the use and management of a BIPAP device (bilevel positive airway pressure device - a non-invasive ventilation machine to help breathing) for 1 of 1 resident (R59) reviewed for respiratory care. Findings include:R59's quarterly MDS assessment dated [DATE], identified R5 had intact cognition with no hallucinations or delusions. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator (to include BiPAP and CPAP in section G2 and G3 below) was not marked with a check mark to indicate use. Under section Z1: none of the above: was marked with a check.During an observation on 5/4/26 at 4:41 p.m., a BiPAP machine was observed sitting on R59's side table by her bed. There was a gallon of water next to the machine. R59 indicated staff assist with her with the machine at night.R59's care plan,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · 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 fully addressed, including providing a rationale in the resident's medical record if no changes in medication were to be made for 1 of 5 residents (R5) reviewed for unnecessary medications. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderately impaired cognition and was diagnosed with diabetes, Alzheimer's disease, and anxiety.R5's pharmacist Consultation Report dated 11/5/25, indicated R5 received 6 milligrams (mg) of melatonin at bedtime since 7/21/23 for insomnia. The report indicated that melatonin was not recommended for sleep onset or sleep maintenance insomnia in adults. The report indicated that melatonin does not induce or maintain sleep but helps to set the hour of sleep and should not be used beyond six weeks. The report indicated the adverse reactions of melatonin include confusion, daytime drowsiness, dizziness, vivid dreams or nightmares,…
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 · D2025-03-27 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 inform in advance and obtain consent for psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R22 had severe cognitive impairment, felt down, depressed or hopeless 2-6 days of the 14 day look back period, required moderate to substantial assistance with most activities of daily living (ADLs) and was taking antipsychotic and antidepressant medication. R22's diagnoses included Alzheimer's, dementia, depression and hallucinations. R22's care plan dated 2/25/25, indicated R22 used antipsychotic and antidepressant medications and was at risk for behaviors related to hallucinations. R22's March, 2025 medication administration record (MAR) indicated: Escitalopram Oxalate Oral Tablet 5 MG (Lexapro). Give 1 tablet by mouth one time a day for anxiety AEB (as evidenced by) reports of anxiety, restless physical movements, repetitive questions about…
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 · D2025-03-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is 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 activities of daily living (ADLs) were completed, including shaving for 1 of 1 resident (R22) reviewed for grooming. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R22 had severe cognitive impairment, required partial to moderate assistance with personal hygiene including shaving, and did not exhibit rejection of care. R22's diagnoses included Alzheimer's, dementia, lack of coordination, and need for assistance with personal cares. R22's care plan dated 2/25/25, indicated R22 had an ADL self-care deficit related to diagnoses and impaired balance. The care plan instructed staff to assist R22 with personal hygiene and cares. R22's [NAME] printed 3/25/25, indicated R22 required assistance with cares and instructed staff to keep his routine as consistent as possible. R22's shaving task dated 2/24/25 through 3/24/25 indicated, Resident *MUST* be shaved. A check mark was documented once each day under 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 · Dcited before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure wounds were accurately assessed and reported appropriately when thought to be deteriorating for 1 of 3 residents reviewed for wound assessment and monitoring. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had severe cognitive impairment, required substantial/maximal assistance with personal cares and mobility, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers but did not have any at the time of the assessment. The MDS further indicated R32 did not exhibit physical or verbal behaviors towards others and did not reject cares. R32's diagnoses included dementia, type 2 diabetes, congestive heart failure, and kidney disease. R32's care plan revised 12/31/24, indicated R32 had potential for pressure ulcer development related to immobility, incontinence, and diabetes. The care plan instructed staff to monitor/document/report PRN [as needed] any changes in skin…
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 before2025-03-27 · 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 performed for 1 of 3 residents (R24) observed during personal cares and 1 of 1 residents (R24) observed during wound cares. Furthermore, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 residents (R24) observed for EBP. Findings include: R24's quarterly Minimum Data Set, dated [DATE], indicated he had intact cognition and required partial to moderate assistance with personal hygiene. The MDS reported diagnoses of kidney failure, high blood pressure, depression and chronic pain. The MDS also reported his use of an indwelling urinary catheter and identified he had one venous ulcer. R24's care plan identified his catheter use and need for EBP. The care plan also indicated he had an activities of daily living (ADL) self-care performance deficit related to his left leg amputation and limited mobility. The care plan directed staff to provide extensive assistance with personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-02 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to recognize and report injuries of unknown origin to the administrator and/or the State Agency (SA) for 4 of 4 residents (R18, R57, R30, and R46) with suspicious bruises. Findings include: R18 During observation on 4/10/24, at 8:30 a.m., R18 was observed seated in a Broda (reclining wheelchair) in the activity room. R18 had a fading purple bruise approximately two inches in diameter on the left side of R18's chin and neck area. R18 was unable to respond when questioned about the bruise. During interview on 4/10/24 at 12:11 p.m., family member (FM)-A stated R18 had sustained a large bruise on the left side of their chin/neck area; however, the facility was unable to explain to FM-A how the bruise occurred. R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 as…
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 before2024-05-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed ensure transfer interventions were consistently implemented for 1 of 1 resident (R18) reviewed for injuries of unknown origin. Additionally, the facility failed to implement interventions for monitoring and documenting bruising for 2 of 2 residents (R30 and R46) reviewed for injuries of unknown origin. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and diagnoses which included dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 weighed less than 100 pounds and required substantial/maximal assistance with transfers. R18's care plan dated 10/23, directed staff to provide extensive assistance of two staff for transfers. During observation on 4/11/24 at 11:05 a.m., R18 was seated in a Broda chair (reclining wheelchair) next to R18's bed. Nursing assistant (NA)-A stood in between the chair and the bed, squatted in front of R18 and directed R18 to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and monitor the bruise on R18's left facial area, R46's right and left forearm, right and left anterior legs, and right and left inner thigh and failed to accurately document the location and monitor R30's bruise of unknown origin of four residents reviewed for quality of care. Findings include: R30 Interview of R30 on 4/30/24 at 3:50 p.m., revealed the resident was alert, but oriented to person only. The resident reported leaving the facility and planning to move back to the United States. On 4/3024, review of a nursing progress dated 4/2/24 at 10:05 p.m., revealed R30 is a [AGE] year old senior who has been residing in the facility over a year. R30's family reported to registered nurse (RN)-C that a bruise was noted on resident's left lower extremity. RN-C assessed and documented that a bruise of four inches was noted from the resident's left of middle calf to left foot. When asked, R30 was unable to recall. Therefore, RN-C and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · 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 to minimize the development of pressure ulcer risk for 1 of 1 resident (R18) in accordance with the individualized care plan. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease and anxiety disorder. The MDS also identified R18 was at risk for the development of pressure ulcers and requiring substantial/maximum assistance with bed mobility and transfers. R18's pressure ulcer Care Area Assessment (CAA) dated 1/9/24, indicated R18 was at risk for the development of pressure ulcers. R18's Braden Scale (pressure ulcer risk assessment) dated 4/3/24, identified R18 at moderate risk for the development or pressure ulcers. R18's care plan dated 10/31/23, identified R18 at risk for the development of pressure ulcers and directed to reposition R18 every two…
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 before2024-05-02 · 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 provide adequate supervision during the provision of care for 1 of 1 residents (R18) observed to be transferred inappropriately and had an injury of unknown origin. In addition, the facility failed to provide adequate supervision including an assistance devices, anti-roll back, timely for R46. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 as weighing less than 100 pounds and requiring substantial assistance with transfers. R18's care plan dated 10/23, directed staff to provide extensive assistance of two staff for transfers. R18's clinical record lacked a comprehensive transfer assessment. R18's Progress Note (nurses note) dated 3/27/24 at 6:00 a.m., indicated a night nursing assistant (NA)-E had reported a, big bruise on the left…
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 before2024-05-02 · 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 provide timely assistance with incontinence cares for 1 of 1 resident (R18) in accordance with the individualized care plan. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease and anxiety disorder. The MDS also identified R18 as being dependent on staff for toileting hygiene, frequently incontinent of bowel and bladder and requiring substantial assistance with transfers. R18's urinary incontinence Care Area Assessment (CAA) dated 1/9/24, indicated R18 was incontinent of urine and required extensive assistance for toileting. R18's Comprehensive and Restorative Bowel and Bladder Evaluation dated 4/8/24, directed the staff to provide scheduled incontinent care and comfort. R18'2 care plan dated 10/31/23, directed the staff to check R18 every two hours and assist with toileting as needed.…
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 · D2024-05-02 · 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 observation, interview and document review, the facility failed to provide nonpharmacological interventions prior to the administration of as needed antianxiety medications for 1 of 1 resident (R18) utilizing antianxiety medications. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease and anxiety disorder. The assessments indicated R18 displayed no mood or behavior concerns. R18's psychotropic medication Care Area Assessment (CAA) dated 1/9/24, indicated R18 received psychotropic medications for behavior management. The CAA did not include nonpharmacological interventions the staff were attempt prior to the administration of medications. R18's physician orders dated 2/26/24, indicated R18 had been receiving Lorazepam (Ativan- antianxiety medication) .5 milligram (mg) in the morning and 1 mg in the evening since 1/23/24. However, on 2/26/24, the order 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.
- No harm found · B2024-05-02 · tag F0623 — patternProvide 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
Based on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 of 12 residents (R72, R19, R175, R27, R45, R174, R12, R47, R173, R69, R171, R44) who had been hospitalized . Findings include: An e-mail correspondence with the OOLTC, dated 4/3/24, identified the facility had not completed monthly reporting of transfers and discharges to the OOLTC as required. R19's HSN dated 1/1/24, identified R19 transferred to the hospital emergency department (ED) for further evaluation for unresponsiveness. HSN dated 1/4/24, identified R19 readmitted to the facility. The medical record lacked evidence notice of the transfer was provided to the OOLTC. R175's HSN dated 1/6/24, identified R175 transferred to the hospital for evaluation of low oxygen saturation. The medical record lacked evidence notice of the transfer was provided to the OOLTC. R27's HSN dated 1/7/24, identified R27 transferred to the hospital per family request. The HSN dated 1/13/24, identified R27 was readmitted to the facility. R27'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.
“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
$99,500 in federal fines across 1 penalty.
- $99,500 — penalty dated 2024-05-02
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 LIFESPACE COMMUNITIES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 3.7 | -0.7 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 14 homes this chain runs (chain average 4.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIFESPACE COMMUNITIES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 07/08/2009 |
| BEVER, JENNIFER | Individual | W-2 MANAGING EMPLOYEE | — | since 11/09/2015 |
| BLACKFORD, GARY | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| DARKEY-HRINYA, JOYCE | Individual | CORPORATE DIRECTOR | — | since 01/15/2018 |
| DUTRA, ANA | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| FIELDS, VENITA | Individual | CORPORATE DIRECTOR | — | since 01/15/2018 |
| JENSEN, CLAUS | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| MCDONOUGH, AMY | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SALAMINO, JENIFER | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SOKEYE, JONATHAN | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| SPANGLER, PATRICK | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| STRETCH, CLYDE | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| WILLIAMS, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| YANOFSKY, NEAL | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| GORMAN, JOSEPH | Individual | CORPORATE OFFICER | — | since 07/26/2022 |
| HAMM, SARA | Individual | CORPORATE OFFICER | — | since 03/30/2015 |
| HARSHFIELD, NICHOLAS | Individual | CORPORATE OFFICER | — | since 07/01/2020 |
| JANTZEN, JESSE | Individual | CORPORATE OFFICER | — | since 06/22/2021 |
| KRESSE, NIKKI | Individual | CORPORATE OFFICER | — | since 04/19/2021 |
| POPE, ERIN | Individual | CORPORATE OFFICER | — | since 07/25/2022 |
CMS files one row per role, so the 21 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.0M 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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Minnesota Medicaid page for homes that do.
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 245229. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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 →
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