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The Estates At Bloomington LLC

9200 Nicollet Avenue South, Bloomington, MN 55420 · For profit - Limited Liability company · 68 certified beds · (952) 881-8676 Medicare & Medicaid certified

Call the home — (952) 881-8676 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 17% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
8936 LYNDALE Ave · (952) 881-0163 · Call to confirm hours
Pharmacy
Cvs0.6 mi
8936 Lyndale Ave S · (952) 881-0163 · Call to confirm hours
Grocery
9070 Lyndale Ave S · (952) 600-7618 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.0%18.2%15.4%worse
Long-stay residents who lose too much weight5.1%4.1%5.4%typical
Long-stay residents with a catheter left in their bladder0.3%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%2.6%2.0%better
Long-stay residents with depressive symptoms0.5%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%4.0%3.3%better
Long-stay residents whose ability to walk worsened18.1%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication5.6%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.6%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control14.4%24.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.6%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine98.3%82.7%79.4%better
Short-stay residents rehospitalized after admission22.8%23.5%22.6%typical
Short-stay residents with an outpatient ER visit6.7%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.291.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.441.901.80better

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.

40.9% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.9%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
44.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 44.0% 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 25 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF40.9%CMS range 28.7–53.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.4–16.410.7%Oct 2022–Sep 2024no 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 discharge44.0%56.6%Oct 2024–Sep 2025CMS 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 discharge48.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.0%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.5–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS 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

1.13
RN hours/ resident / day
0.39
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
1.01
RN hoursweekends
37.1%
Total nursing turnover
47.4%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 65.9 residents a day — about 97% 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.13 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 3.02 hrs/resident/day on weekends vs 3.45 on weekdays — 12% thinner on weekends. RN hours go from 1.17 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-04-23)
11
at the previous standard inspection (2025-01-30)

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.

ABCDEFGHIJKL

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.

33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · Gcited before2024-01-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 implement transfer interventions for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who hit her head and sustained a skin tear on the left forearm. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 required extensive assistance of two staff with the use of a mechanical lifting device for transfers. R1's Brief Interview for Mental Status (BIMS) indicated a score of 15, cognitively intact. R1's care plan last revised on 10/03/23, indicated R1 had a diagnosis of rheumatoid arthritis, adult failure to thrive, hypertension, depression, anxiety, obesity, and peripheral vascular disease. Self-care interventions included transfer assist of two using a mechanical lift. A progress note, dated 07/12/23, indicated that R1 fell during a transfer with the mechanical lift due to a strap falling off. R1 fell onto the wheelchair. R1 hit her head and sustained a skin tear on her left forearm. R1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dignity was maintained for 2 of 2 residents (R9, R13) reviewed for dignity when staff failed to knock, introduced themselves, and wait for permission to enter resident rooms prior to entry.Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with dementia, psychosis and dependent on staff for all cares. In addition, R9 was enrolled in hospice.R13R13's quarterly MDS dated [DATE] identified R13 was cognitively intact and had diagnoses of fibromyalgia, anxiety, depression and chronic pain.During observation and interview on 4/20/26 at 2:30 p.m., the State Agency (SA) surveyor was in process of screening R13 in their room which was shared with R9. The bedroom door to hallway was closed and a privacy curtain was pulled around R13 who was lying on bed. Nursing assistant (NA)-A entered the room with R9 who was seated in Broda wheelchair. During this time NA-A failed to knock, introduce herself, and wait for permission 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and record review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 1 of 1 residents (R9) reviewed for call lights.Findings include:R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with impaired cognition, no limitation in upper extremity range of motion and dependent on staff for turning, repositioning, transfers, and all personal cares. R9's diagnoses include dementia. In addition, R9 was enrolled in hospice.During observation on 4/20/26 at 2:30 p.m., nursing assistant (NA)-A wheeled R9 into the middle of their room without placing a call light in reach and then turned around and left the room without speaking. R13's call light was on R13's bed which was approximately 15 feet away. During interview upon leaving R13's room, NA-A confirmed R13 was not able to use her legs and would not have been able to reach the call light while seated in the middle of the room. During observation on 4/21/26 at 9:00 a.m., R9 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 written transfer notice and notice of bed hold for 1 of 1 residents (R4) reviewed for hospitalization.Findings include:R4's admissions Minimum Data Set, dated [DATE] identified R4 with impaired cognition, required assistance with all personal cares, and diagnoses of hemiplegia (form of paralysis affecting one side of the body), diabetes and anxiety.R4's electronic medical record (EMR) progress notes lacked indication of a hospitalization or emergency room visit since admission to facility on 2/18/26.R4's hospital after visit summary dated 4/14/26, identified R4 was transferred to the emergency room for diarrhea.During interview with R4 on 4/20/26 at 1:27 p.m., R4 stated she had had a hospitalization for diarrhea recently but did not know what the date was. In addition, R4 could not recall whether she was offered or provided a transfer form or bed hold notice at the time of the emergency room visit.R4's emergency contact was called 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement, or revise as needed, a comprehensive, person-centered care plan with individualized interventions for 1 of 1 resident (R67) reviewed for fluid management, related to the resident's diagnosis of polydipsia (excessive, persistent thirst or compulsive, excessive water consumption) and ongoing fluid-seeking behaviors Findings include:R67's quarterly Minimum Data Set (MDS), dated [DATE], indicated R67 was admitted to the care facility on 10/25 and had severe cognitive impairment. R67's Diagnoses, dated 10/25/24, indicated R67 had a diagnosis of polydipsia. R67's care plan, dated 10/29/24, indicated a risk versus benefit form was completed and on file for R67 for not following the recommended diet related to the diagnosis of polydipsia. The care plan also indicated R67 was observed trying to get drinks from other residents and drinking water out of the bathroom sink. The care plan contained interventions, dated 3/24/25 of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 and complete respiratory care documentation and resident-specifc ordered settings for the use and management of a BIPAP device (bilevel positive airway pressure device - a non-invasive ventilation machine to helps in breathing) for 1 of 1 resident (R17) reviewed for respiratory care. Findings include:R17's quarterly Minimum Data Set (MDS), dated [DATE], indicated R17 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 14 (indicating intact cognition), and utilized a non-invasive mechanical ventilator.R17's physician orders, printed 4/23/26, indicated an order for a BIPAP machine to be applied at bedtime (HS), to remain on during nocturnal hours, and to be removed in the morning. Additional orders directed staff to change the BIPAP water daily, including emptying, drying, and refilling the chamber with distilled water to the fill line without overfilling each evening shift. Weekly orders…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic/opioid and non-narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 2 of 6 residents (R5, R28) reviewed for unnecessary medication use. Findings include: R5 R5's admission Minimum Data Set (MDS) assessment, dated 3/19/26, identified R5 had intact cognition with no hallucinations, delusions, verbal or physical behaviors. R5 did reject cares 1-3 times during observation period. In addition, the MDS outlined R5 received both scheduled and PRN pain medications during the review; however, did not receive any non-medication intervention for pain. Further, R5 indicated they had occasional pain which they rated at four (4) out of 10 (10 being the worst possible). R5's care plan, initiated on 3/17/26, identified R5 had an alteration 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation and interview, the facility failed to maintain a safe, comfortable, and homelike environment for 2 of 2 residents (R9, R13) reviewed whose main bedroom ceiling light did not function properly.Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with impaired cognition, no limitation in upper extremity range of motion and dependent on staff for turning, repositioning, transfers, and all personal cares. R9's diagnoses include dementia. In addition, R9 was enrolled in hospice. R13R13's quarterly MDS dated [DATE] identified R13 with intact cognition and diagnoses of fibromyalgia, anxiety, depression and chronic pain.During observation and interview with R13 on 4/20/26 at 2:31 p.m., R13 pointed to flickering ceiling light and stated it had not worked for a long time. R13 stated she was frustrated, to have that strobe light [NAME] on and off which caused her headaches. R13 stated she had to currently use the pull string light over the head of her bed instead,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure community use glucometers (machines to check blood sugar) were properly cleaned and disinfected between patient use, and failed to ensure staff who performed blood glucose checks were knowledgeable of process for cleaning and disinfecting blood glucose devices prior to and after use per manufacturer instructions. This had the potential to affect 9 of 9 (R10, R13, R15, R26, R29, R41, R49, R54, and R118) residents who were diabetic, had orders for blood glucose monitoring, and used a community glucometer. Findings include: The manufacturer's instructions for use of the Arkray Assure Platinum Blood Glucose Monitoring System in Section B: To reduce the chance of infection, the clinician is to, Wash hands thoroughly with soap and water before putting on a new pair of gloves and performing the next patient test. And, prior to obtaining blood sample, Step 1: Wash patient's hands with soap and warm water. Guidelines for cleaning and disinfecting the unit state, To minimize the risk of transmitting blood-borne…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a comfortable and homelike environment for 2 of 2 residents (R19, R23) who shared a room with a large area of the wall patched but left unfinished, unsanded, and unpainted. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had intact cognition. R23's annual MDS dated [DATE], identified had intact cognition. During observation and interview on 1/27/25 at 6:01 p.m., a shared wall of R19 and R23's room had an area of white joint compound that measured one hundred and three inches long by thirty-seven inches tall spanning most of the wall. The area was not sanded, smoothed out, or painted to match the rest of the wall and room. R23 stated, the wall has been like this since [sic] moved to this room in October of 2024. During interview with registered nurse (RN)-B on 1/28/25 at 10:01 a.m., RN-B stated she was familiar with all the residents. RN-B stated there was an expectation of staff to notify the maintenance staff…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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 dental appliances (i.e., dentures) were offered or provided to promote safety and independence with eating for 1 of 4 residents (R60) reviewed for activities of daily living (ADL). Findings include: R60's quarterly Minimum Data Set (MDS), dated [DATE], identified R60 had severe cognitive impairment and demonstrated no rejection of care behaviors. Further, the MDS outlined R60 needed substantial and/or maximum assistance to complete oral hygiene (inc. dentures). R60's most recent MHM (Monarch Healthcare Management) Oral/Dental Evaluation, dated 11/18/24, identified R60's oral cavity had no issues and R60 used an upper and lower denture with their condition being recorded, Good condition. R60 was recorded as edentulous (no natural teeth) and a summary outlined, Resident wears full upper and lower dentures. He denies pain with chewing. He is dependent on staff to perform oral hygiene. No mouth sores noted with oral inspection. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Dcited before2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine nail care was provided for 1 of 1 resident (R58) reviewed for activities of daily living (ADLs) who needed assistance from staff for nail care. Findings include: R58's quarterly Minimum Data Set (MDS) dated [DATE] indicated, R58 was cognitively intact, had no behaviors and did not refuse cares. MDS indicated R58 was independent with ADLs and needed set up or clean up assistance with showers. R58's Clinical Diagnosis Report printed 1/30/25, indicated diagnoses of gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), generalized muscle weakness, other reduced mobility, need for assistance with personal care, protein calorie malnutrition and failure to thrive. R58's ADLs care plan printed 1/30/25 indicated R58 needed assistance with personal cares. An undated Group Report Sheet used by nursing assistants to know how to care for the residents, indicated R58 needed assistance of one…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 assess and, if needed, develop interventions or refer to contracted therapy services to address poor wheelchair posture for 1 of 2 residents (R60), and failed to provide assessed interventions from occupational therapy to reduce the risk of skin injury or further mobility loss (i.e., contracture worsening) for 1 of 1 resident (R15) reviewed for limited range of motion (ROM). Findings include: R60 R60's quarterly Minimum Data Set (MDS), dated [DATE], identified R60 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R60 had a functional limitation in range of motion (ROM) to both lower extremities and used a wheelchair for mobility. On 1/27/25 at 1:36 p.m., R60 was observed seated in a standard wheelchair in the hallway. R60 stated he was unsure how long he had lived at the center and presented with mostly mumbled responses which, at times, were non-sensical.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an order for an audiology (medical specialty assisting with hearing) referral was acted upon promptly to promote better hearing and quality of life for 1 of 1 residents (R13) reviewed who expressed difficulty with hearing. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition with no delusional thinking. The MDS indicated R13 had adequate hearing (i.e., no difficulty in normal conversation) and did not use hearing aids. R13's referral form dated 2/22/24, indicated R13 had an order from her provider for an audiology consult for a diagnosis of hearing loss. R13's provider note dated 7/1/24, indicated R13 had reported worsening hearing loss and as a result, withdraws from social interaction and stays in her room. The note indicated the plan for the resident's hearing loss was to provide an audiology consult. During an interview on 1/27/25 at 1:46 p.m., R13 stated she had needed her ears checked…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 an unsecured bed mattress was assessed for correct fit for a resident's bed for 1 of 1 residents (R59) reviewed for safety hazards. Findings include: R59's quarterly Minimum Data Set, dated [DATE] identified R59 had intact cognition and was independent with most mobility related activities (i.e., dressing, toileting and personal hygiene, and ambulation). In addition, R59 had diagnoses of cellulitis (bacterial infection of the skin that can cause redness, pain and swelling at the site) of left lower extremity, anxiety, and depression. During observation and interview with R59 on 1/27/25 at 1:26 p.m., R59 was observed to be lying in bed which was positioned along the wall with the foot of the bed just inside door to hallway. The bed had no footboard, and the unsecured mattress hung over the foot of the bed frame by about 12 inches. There was no retainer bar at the foot of the bed frame to prevent mattress from sliding down. R59…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure ongoing monitoring of resident oxygen use was completed to reduce the risk of respiratory complications for 1 of 1 residents (R13) reviewed for oxygen use. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition and was diagnosed with heart failure, kidney failure, Chronic Obstructive Pulmonary Disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness), and respiratory failure. The MDS indicated R13 required setup help with eating and oral hygiene and maximum assistance with dressing. The MDS indicated R13 was on oxygen therapy. R13's care plan dated 9/7/24, indicated R13 had an alteration in respiratory status and would remove her oxygen cannula and adjust her oxygen administration rate herself. R13's care plan indicated oxygen was to be administered as ordered and oxygen saturations were to be monitored. The care plan indicated staff…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 accurately or comprehensively assess the use of side rails and ensure installed side rails were secured to prevent injury or potential entrapment for 1 of 1 resident (R33) reviewed who used bilateral quarter-sized side rails on their bed. Findings include: R33's admission Minimum Data Set (MDS), dated [DATE], identified R33 had intact cognition and demonstrated no delusional thinking. Further, the MDS outlined R33 required substantial and/or maximum assistance for bed mobility. On 1/27/25 at 1:14 p.m., R33 was observed lying in bed while in her room. R33 used a standard-size hospital bed and each side had a mounted, affixed metallic one-quarter side rail attached to the frame via a center arm. The rail on the open side of the bed (opposite the wall) was loose when touched and allowed movement of approximately eight to 10 inches back-and-forth towards and away from the bed which increased the spacing between the mattress and rail. R33…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 consulting pharmacist recommendations were fully addressed or acted upon for 1 of 5 residents (R13) reviewed for unnecessary medications. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition and utilized antipsychotic, antianxiety, and antidepressant medication. R13's diagnostic report dated 7/1/24, indicated R13 was diagnosed with major depressive disorder, bipolar disorder, and an anxiety disorder. R13's Order Summary report dated 1/30/25, included the following orders: -dated 6/2/23 for 200 milligrams (mg) of quetiapine (an antipsychotic medication used to treat bipolar disorder) daily for bipolar disorder. -dated 8/14/23 for 300 mg of bupropion XL (an antidepressant) daily for major depressive disorder. -dated 8/14/23 for 120 mg of duloxetine (an antidepressant) daily for major depressive disorder. -dated 8/14/23 for 400 mg of lamotrigine (an anticonvulsant sometimes used to treat…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 ensure acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded to ensure efficacy of as-needed (i.e., PRN) psychotropic medication for 1 of 5 residents (R2) reviewed for unnecessary medication use. Findings include: R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had severe cognitive impairment and continuous inattention, disorganized thinking, and altered consciousness. The MDS recorded R2 having multiple signs of potential depression, including appear or feeling down and being short-tempered, but demonstrated no behaviors (i.e., physical, verbal, other). Further, the MDS identified R2 consumed multiple psychotropic's including both antipsychotic and antianxiety medications. R2's Doctor's Order, dated 1/6/25, identified an order from hospice was received which read, Restart lorazepam concentrate . 0.5 mg [milligrams] (0.25 ml) PO/SL [by…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to verify orders written by a provider for one of one resident (R1) reviewed. R1 had orders for wound care treatments and the facility thought the orders were written in error but did not verify the orders with the provider. Findings include: R1's medical records indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of cellulitis of right lower limb. R1's additional diagnoses included venous insufficiency, muscle weakness, chronic kidney disease stage three, and anemia. R1's wound care progress note dated 7/24/24 indicated nurse practitioner (NP) ordered staff to clean vascular ulcer dorsum second interdigital on R1's right side daily and paint daily with Betadine. R1's wound care progress note dated 7/31/24 indicated nurse practitioner (NP) ordered staff to clean vascular ulcer dorsum second interdigital on R1's right side daily and paint daily with Betadine. R1's treatment administration record dated July 2024 indicated R1 did 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report a fall with injury caused by not following the care plan to the State Agency (SA) for 1 of 1 resident (R1) reviewed for falls. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 required extensive assistance of two staff with the use of a mechanical lifting device for transfers. R1's Brief Interview for Mental Status (BIMS) indicated a score of 15, cognitively intact. R1's care plan last revised on 10/03/23, indicated R1 had a diagnosis of rheumatoid arthritis, adult failure to thrive, hypertension, depression, anxiety, obesity, and peripheral vascular disease. Self-care interventions included transfer assist of two using a mechanical lift. A progress note, dated 07/12/23, indicated R1 fell during a transfer with the mechanical lift due to a strap falling off. R1 fell onto the wheelchair. R1 hit her head and sustained a skin tear on her left forearm. R1 declined an evaluation at the emergency department. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-12 · tag F0572 — isolated
    Give residents a notice of rights, rules, services and charges.
    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 notice of rights and services to 2 of 3 residents (R1 and R4) reviewed for rights prior to or upon admission. Findings include: The facilities MN admission Packet undated, included: admission Agreement, Rate and Special Services Sheet, Personal Belongings Inventory, Explanation of Arbitration Agreement Language to Family and Resident/Patient, Arbitration Agreement, Electronic Monitoring Requirements in Minnesota, Photograph and Video Release Form, Leave of Absence and Discharging Against Medical Advice Progress, Acknowledgement Form and Notice of Privacy Practices. The admission packet policies included the facility Substance Use and Resident Smoking. R1's admission Minimum Data Set (MDS) dated [DATE] was not completed as R1 discharged from the facility the same day as he was admitted . R1's progress notes dated 12/1/23 at 1:12 a.m. indicted R1 was admitted to the facility on [DATE] at approximately 6:00 p.m. R1's family called 911 and R1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on interview and record review, the facility failed to report an allegation of abuse immediately but not later than 2 hours after the allegation was made to the State Agency (SA) and administrator for one of one resident (R3) reviewed abuse. Staff received an abuse allegation from R3 and did not report the allegation to the administrator or SA. Findings include: R3 ' s admission care plan date 7/8/22, indicated a focus for being vulnerable adult and is at risk for abuse with a goal to remain free from abuse that was revised on 10/3/23 with an intervention initiated on 7/19/22 for all staff to be aware of statements or signs/symptoms of abuse, staff will continue to follow the facility ' s policy vulnerable adult & abuse reporting policy. R3 ' s progress notes dated 12/4/23 to 12/7/23 did not indicate an allegation of abuse between R3 and staff. R3 ' s medical record did not indicate progress notes from 12/8/23 to 12/10/23. During an interview with R3 on 12/11/23 at 12:30 p.m., R3 stated that registered nurse (RN)-F verbally threatened her on 12/8/23 during the evening shift…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 resident and/or resident representative participation in the care planning process and subsequent interventions for 1 of 1 residents (R35) reviewed for participation in care planning. Findings include: R35's admissions Minimum Data Set (MDS) dated , 10/2/23 identified R35 with a facility admission date of 9/26/23. In addition, listed R35 with moderately impaired cognition and an overall goal to discharge to the community. Social work progress note dated 9/28/23 at 10:40 a.m., indicated the initial care conference was completed and, Resident discharge plan is to return home after physical therapy. During interview with R35 on 11/5/23 at 3:43 p.m., R35 stated facility failed to communicate with him regarding discharge planning. R35 stated, I want to discharge. During interview with social worker (SW)-A on 11/6/23 at 3:25 p.m., SW-A stated resident care conferences are expected to be done within at least 24 hours of admission and within 21 days of admission after therapy, dietary, nursing, social worker, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 document review, the facility failed to refer a resident for a level II pre-admission screening and resident review (PASARR) evaluation and determination for one of one resident (R33) reviewed for PASSAR who had a new diagnosis of paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally) diagnosis. Findings include: R33's quarterly Minimum Data Set (MDS), dated [DATE], indicated R33 was admitted on [DATE], was independent with activities of daily living (ADLs) and had intact short-term and long-term memory. R33's Diagnoses List, dated 11/8/23, indicated R33 was admitted to the facility with several medical diagnoses including major depressive disorder, personality disorder and suicidal ideations. The listing indicated R33 did not receive a diagnosis of paranoid schizophrenia until 12/30/22. R33's Admit Note from Twin Cities Physicians (TCP), dated 5/14/20, indicated R33 was admitted from Fairview Hospital with no past medical history due to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure bathing or showers were provided for 1 of 1 residents (R5) reviewed for dependent activities of daily living (ADL's). Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE], indicated R5 with intact cognition, diagnoses of anxiety, depression, diabetes, and legal blindness. In addition, listed R5 required extensive assistance of two staff for bed mobility, dressing, toileting, personal hygiene, and bathing support. R5's care plan (CP) dated 8/7/23, indicated R5 received monitoring of skin integrity with daily cares and weekly skin inspection by nurse. During interview with R5 on 11/5/23 at 12:28 p.m., R5 stated she did not receive, enough baths or showers. During interview with R5 on 11/7/23 at 9:10 a.m., R5 stated she did not receive her scheduled bath on 11/4/23. R5 stated, I am used to getting baths and showers every day before I got here. During interview with nursing assistant (NA)-A on 11/7/23 at 9:22…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 deliver pressure ulcer care consistent with professional standards of care to prevent a facility acquired pressure ulcer for one of one resident (R41) reviewed for pressure ulcers. Findings include: R41's quarterly Minimum Data Set (MDS), dated [DATE], indicated R41 was cognitively impaired with short term and long term memory problems and required extensive assistance with all activities of daily living (ADLs) except eating. The MDS further indicated R41 did not have any pressure ulcers. R41's Braden Scale Assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries), dated 8/29/23, indicated R41 was at moderate risk for skin breakdown. R41's Progress Note, dated 10/3/23, indicated R41 was noted to have an open area to her coccyx. R41's Integrated Wound Care note, dated 10/25/23, indicated R41 had a stage three (III) facility acquired…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview and policy review, the facility failed to ensure medications were securely and safely stored in 2 of 4 medication carts observed. Findings include: During observation on 11/06/23 at 7:05 a.m., an unattended medication cart located on the 300 wing of facility adjacent to resident room [ROOM NUMBER] was observed to be unlocked. During interview with registered nurse (RN)-A on 11/6/23 at 7:06 a.m., RN-A stated the two medication carts on the 300 wing of facility adjacent to resident room [ROOM NUMBER] were unlocked and unattended. RN-A stated the carts should be locked when no one is around. During observation on 11/6/23 at 11:53 a.m., an unattended and unlocked medication cart located on the long term care unit (600 wing) with two residents in wheelchairs positioned along the wall directly opposite of the cart. RN-B was observed to be sitting at the nursing station about 20 feet away from the unattended and unlocked medication cart. A maintenance staff member was in close…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 physician-ordered thickened liquids for 1 of 1 residents (R268) reviewed for therapeutic diets. Findings include: R268 did not have MDS data available. R268's Diagnosis Information dated 11/2/23, indicated R268 was diagnosed with severe malnutrition, diabetes, and dysphagia (a condition causing difficulty swallowing). R268's Hospitalist Discharge summary dated [DATE], indicated R268 required mildly thick liquids, continuous supervision while eating, fully upright seating while eating and drinking, and small single sips of liquids. R268's progress note dated 11/2/23 at 2:47 p.m., indicated R268 was admitted to the facility on [DATE] and required the assistance of one person to transfer and with toileting activities. R268's order summary dated 11/3/23, indicated R268 required a mechanical soft textured diet with liquids of a nectar consistency. The order dated 11/7/23, indicated R268 required a chest x-ray due to new coughing 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure allegations of potential sexual abuse were reported immediately, but no later than two hours after the allegation is made, to the state agency (SA) for 1 of 1 resident (R4) who alleged being touched down there referencing her vaginal area. Findings include: R4's current care plan (CP) dated 10/25/22 indicated R4 was a vulnerable adult and staff were to be aware of statements or signs/symptoms of abuse, if present update Medical Doctor (M.D.), Director of Nursing (DON) and Administrator immediately. Staff were to follow the facility vulnerable adult and abuse reporting policy. R4's quarterly Minimum Data Assessment (MDS) dated [DATE] indicated R4 had a Brief Inventory of Mental Status (BIMs) score of zero indicating R4 had severe cognitive impairment R4 had unclear speech including slurred or mumbled words. R4 could usually make herself understand could usually understand others. R4 required extensive assistance of two staff members for bed…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 interview, and document review, the facility lacked evidence the allegation of sexual abuse had been thoroughly investigated for 1 of 1 resident (R4) whose family reported sexual abuse allegations to the facility. The findings include: R4's current care plan (CP) dated 10/25/22 indicated R4 was a vulnerable adult and staff was to be aware of statements or signs/symptoms of abuse, if present update Medical Doctor (M.D.), Director of Nursing (DON) and Administrator immediately. Staff were to follow the facility vulnerable adult and abuse reporting policy. R4's quarterly Minimum Data Assessment (MDS) dated [DATE] indicated R4 had a Brief Inventory of Mental Status (BIMs) score of zero indicating R4 had severe cognitive impairment R4 had unclear speech including slurred or mumbled words. R4 could usually make herself understand could usually understand others. R4 required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and bathing. She required the assistance of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-11-08 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure nurse staffing information was posted on the weekend and in a timely manner at the start of the shift. This had potential to affect all 59 residents, staff, and visitors who could wish to review this information. Findings include: During entrance to the nursing home, on 11/5/23 (Sunday), at 12:00 p.m., a one-page document in a hard plastic document holder was observed on a table directly in front of the main entrance of the building. This contained a document titled, Daily Headcount with a date of 11/3/23. The form contained the actual and total hours of registered nurses, licensed practical nurses, trained medication aides, RN nurse managers, health information assistants and certified nursing assistants which was broken down into each respective shift (i.e., day shift, evening shift, night shift). There was no visible nurse staffing information posted or displayed for 11/4/23, or 11/5/23. On 11/5/23 at 5:46 p.m., the posted nurse staff information was dated for 11/3/23 (two days prior). During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-11-08 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 required Level I and/or Level II pre-admission screening(s) (PAS) were completed and/or clarified for 1 of 1 residents (R16) reviewed for pre-admission screening and resident review (PASARR). Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], identified R16 had no hallucinations or delusions and required assistance with her activities of daily living (ADLs). R16 diagnoses included bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs), psychotic disorder with delusions, depression, anxiety disorder, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes, renal insufficiency (kidney disease), and heart failure. R16's Initial Pre-admission Screening (PAS) Results dated 11/10/22, identified R16 didn't have a mental illness (MI) or development disability (DD); however, the PAS identified the Senior…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MONARCH HEALTHCARE MANAGEMENT — 45 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 →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 44 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Hillcrest Health Care, LLCMankato, MN 1 of 5Maplewood Rehabilitation CenterMaplewood, MN 1 of 5The Emeralds At Fairbault LLCFaribault, MN 1 of 5The Emeralds At Grand Rapids LLCGrand Rapids, MN 1 of 5The Emeralds At St Paul LLCSaint Paul, MN 1 of 5The Estates At Excelsior LLCExcelsior, MN 1 of 5The Estates At Lynnhurst LLCSaint Paul, MN 1 of 5The Villas At BrookviewGolden Valley, MN 1 of 5The Villas At New BrightonNew Brighton, MN 1 of 5The Villas At Osseo LLCOsseo, MN 1 of 5The Villas At RobbinsdaleRobbinsdale, MN 1 of 5The Villas At The CedarsSaint Louis Park, MN 1 of 5The Waterview Pines LLCVirginia, MN 1 of 5The Waterview Shores LLCTwo Harbors, MN 1 of 5The Waterview Woods LLCEveleth, MN 1 of 5Villas At Bryn Mawr LLCMinneapolis, MN 2 of 5Bayside Manor LLCGaylord, MN 2 of 5Oaklawn Health Care, LLCMankato, MN 2 of 5Parmly On The Lake LLCChisago City, MN 2 of 5The Estates At Chateau LLCMinneapolis, MN 2 of 5The Estates At Fridley LLCFridley, MN 2 of 5The Estates At Roseville LLCRoseville, MN 2 of 5The Estates At Rush City LLCRush City, MN 2 of 5The Estates At Twin Rivers LLCAnoka, MN 2 of 5The Gardens At Foley LLCFoley, MN 2 of 5The Gardens At Winsted LLCWinsted, MN 2 of 5The North Shore Estates LLCDuluth, MN 2 of 5The Villas At St Louis ParkSaint Louis Park, MN 2 of 5The Villas At St PaulSaint Paul, MN 2 of 5The Villas At The ParkSaint Louis Park, MN 3 of 5Bethany On The Lake LLCAlexandria, MN 3 of 5Laurels Peak Health Care, LLCMankato, MN 3 of 5Meeker Manor Rehablitation Center, LLCLitchfield, MN 3 of 5River Valley Health And Rehabilitation Center LLCRedwood Falls, MN 3 of 5The Estates At St Louis Park LLCSaint Louis Park, MN 3 of 5The Villas At RichfieldRichfield, MN 3 of 5The Villas At RosevilleRoseville, MN 4 of 5Lakeshore Rehabilitation Center LLCWaseca, MN 4 of 5Mala Strana Health Care, LLCNew Prague, MN 4 of 5Sleepy Eye Rehabilitati CenterSleepy Eye, MN

Showing 40 of 44; 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 / managerTypeRoleShareSince
HML LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 03/01/2017
NIJ LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 03/01/2017
SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 03/01/2017
YAZOMA HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 03/01/2017
AREM, JEFFREYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 03/01/2017
STERN, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER20%since 03/01/2017
HALPERT, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR30%since 03/01/2017
JAFFA, NOAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 03/01/2017
LEGUM, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE30%since 03/01/2017
MONARCH HEALTHCARE OPERATING IV LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2017

CMS files one row per role, so the 13 rows in the source record cover these 10 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.

$8.0M
Net patient revenuemost recent cost report
+4.2%
Operating marginrevenue minus expenses
$1.3M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 6%Other / private 26%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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 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

$342per resident / day
operating cost
$10,402per month
≈ monthly operating cost
$357per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

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 245324. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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