Maranatha Care Center
5409 69th Avenue North, Brooklyn Center, MN 55429 · Non profit - Church related · 97 certified beds · (763) 549-9600 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.6% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.5% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.1% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 3.9% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.3% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 47.0% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.7% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.6% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.2% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.5% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 37.8% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.3% | 14.8% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
35.4% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 35.4%CMS range 24.4–50.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.6–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 97 beds and averages 90.8 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.15 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.90 hrs/resident/day on weekends vs 4.38 on weekdays — 11% thinner on weekends. RN hours go from 1.24 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2026-06-02 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure assessment, monitoring, and documentation surrounding PRN (as needed) psychotropic medication administration included resident-specific target behaviors and non-pharmacological interventions for 3 of 3 residents (R1, R2, and R3) reviewed for psychotropic medications.Findings include:R1R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, unclear speech, and impaired vision. R1 had disorganized thinking and no behaviors or rejection of care. R1's diagnoses included non-traumatic brain dysfunction, Alzheimer's, and non-Alzheimer's dementia. R1 received hospice services with a prognosis of less than six months of life.R1's care plan dated 5/27/26, indicated R1 had severe cognitive impairment related to neurocognitive disorder, Alzheimer's disease, and dementia and combative with cares. R1 received psychotropic medications. An intervention dated 6/21/24, directed staff to monitor occurrence for target…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an injury of unknown origin within the two-hours for 1 of 1 resident (R1) who had an injury of unknown origin of the left humerus (the long bone located in the upper arm, from the shoulder to the elbow).Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, unclear speech, and impaired vision. R1 had disorganized thinking and no behaviors or rejection of care. The MDS identified R1's diagnoses included non-traumatic brain dysfunction, peripheral vascular disease, renal failure, Alzheimer's, and non-Alzheimer's dementia. R1 had hospice services with prognosis of less than six months of life. R1 was independent with wheelchair use, required partial and/or moderate assistance with eating and substantial/maximum to dependent on staff for other activities of daily living, such as transfers, dressing, toileting, and bed mobility.R1's abuse and/or neglect care plan focus dated 6/3/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure food safety practices including proper food storage such as labeling and dating foods stored in the kitchen as well as monitoring the temperature of the dishwashers and refrigeration/freezer units and maintaining a sanitary work environment in the main kitchen and kitchenettes on the resident floors. This had the potential to affect 85/87 residents. Findings include: Food storage During the initial kitchen tour on 03/31/2025, at 7:17 a.m., the following items were discovered in the walk-in refrigerator without proper label/date; 12 Quart clear plastic square storage container with a blue lid 1/3 full of unknown cream colored liquid, a small, metal pan of pork cutlets- covered with plastic wrap, breaded meat in an uncovered, flat, metal pan, diced onions in clear plastic, square, covered container with plastic wrap, four separate small, metal pans - contained rice, mashed potatoes, chicken breast, and sliced zucchini as well as 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.
- Potential for harm · D2024-12-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) was reviewed and/or revised following a change in condition comprehensive assessment for 1 of 1 residents (R1) reviewed. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of chronic kidney disease, dementia, and malignant neoplasm of sigmoid colon. Further, R1's cognition was noted to be moderately impaired. R1's POLST dated 9/13/24, which was signed by R1's health care agent and family member (FM)-A, indicated R1's wishes were to be do not attempt resuscitation (DNR), allow natural death, in the event R1 had no pulse and was not breathing, as well as comfort-focused treatment (allow natural death) to relieve pain and suffering through the use of any medications by any route, positioning, wound care, and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to monitor and evaluate response to interventions for 1 of 1 resident (R1) identified to have been taking antibiotics for a urinary tract infection (UTI). Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of chronic kidney disease, dementia, and malignant neoplasm of sigmoid colon. Further, R1's cognition was noted to be moderately impaired. R1's medication administration record (MAR) and treatment administration record (TAR) for the month of November 2024, indicated Keflex 500 milligram (mg) twice daily for UTI until 11/15/24, ordered on 11/13/24 and Macrobid 100 mg twice daily for retention of urine for 5 days begin on 11/8/24 discontinued on 11/12/24. Further on 11/8/24, refer to infection progress note template for assessment and documentation requirements. Document at least with the start and the end of an antibiotic regimen and during the course of treatment with clinical change or vital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper glove use and hand hygiene was performed during assistance with toileting and incontinence care for 2 of 4 residents (R5, R4) reviewed for toileting needs. Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE] indicated R5 needed extensive assistance with personal hygiene. On 7/11/24 at 9:30 a.m., nursing assistant-A (NA-A) entered R5's room to assist him to the bathroom. NA-A assisted R5 to the bathroom and placed gloves on without performing hand hygiene. NA-A assisted R5 to stand after he was done urinating and wiped his peri area and buttocks with toilet paper. Urine was in the toilet. NA-A took off the soiled gloves, and without performing hand hygiene, assisted R5 to pull up his pants and sit in his wheelchair. NA-A assisted R5 back to his bedside in his wheelchair, and placed the TV on for him to watch. NA-A washed her hands prior to exiting the room. R4's annual MDS dated [DATE] indicated R4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure injuries of unknown origin were reported to the State Agency (SA) immediately (within two hours) for 1 of 2 residents (R1) reviewed for injuries of unknown source. Findings include: On 3/25/24 at 3:10 p.m., a facility reported incident (FRI) submitted to the SA indicated R1 had bruises of unknown origin. These included bruising on her left upper inner arm measuring 30 centimeters (cm) x 5cm, the left palm of her hand measuring 4 cm x 1 cm, her left shoulder measuring 5 cm x 4 cm, and a skin tear to her left knee measuring 5 cm x 4 cm. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment, and had a diagnosis of dementia. The MDS indicated R1 required substantial to maximum assistance of staff for all personal care and transfers. The MDS also indicated R1 was non-ambulatory, required a manual wheelchair for all locomotion, and she had a history of falls. On 3/23/24 at 2:15 a.m. a progress note indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility failed to ensure dignity was maintained for 1 of 1 (R71) reviewed for dignity. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated R71 had severe impairment of cognition, did not speak and was nonresponsive. In addition, R71 had diagnoses of traumatic brain dysfunction, seizure disorder, dysphagia (with gastrostomy tube), and cognitive communication deficit. In addition, R71 was dependent on staff for all activities of daily living (ADL's) for all cares including bathing, dressing, and hygiene. R71's care plan (CP) with revision date of 8/29/23 indicated, Dressing, Grooming, Hygiene: I require assist of 2. During interview with family member (FM)-A and emergency contact on 2/12/24 at 5:00 p.m., FM-A stated, she'd [R71] be very uncomfortable with her pants left down while in bed. FM-A stated she had observed R71 with pants down below the knees while R71 was in bed. FM-A stated she had, talked with [designated social services (SS-D)] about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 document review, the facility failed to ensure resident call lights were accessible for 3 of 3 residents (R8, R67, R195) reviewed for call lights. Findings include: R8 R8's quarterly Minimum Data Set (MDS) dated [DATE] indicated R8 had severe cognitive impairment and required assistance for all hygiene, dressing, and mobility. In addition, R8 had diagnoses including dementia, coronary artery disease (impaired blood flow to the heart), and renal disease. R8's care plan (CP) dated 8/7/22 indicated, Place call light within reach and answer promptly. During observation on 2/12/24 at 3:12 p.m., R8 was sleeping in bed with the call light looped through a plastic tube attached to bed frame aligned with R8's left shoulder. However, the controller for the call light was laying on the floor out of reach of R8. During observation on 2/14/24 at 7:36 a.m., R8 was sleeping in bed with the call light looped through a plastic tube attached to bed frame aligned with R8's left shoulder. However,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the emergency contact (FM-A) in a timely manner for 1 of 1 residents (R71) reviewed for notification of change when R71 required an emergency hospital procedure. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE] indicated R71 had severe impairment of cognition, did not speak and was nonresponsive. In addition, R71 had diagnoses of traumatic brain dysfunction, seizure disorder, oxygen dependency, dysphagia (with gastrostomy tube), and cognitive communication deficit. Also, R71 was dependent on staff for all activities of daily living (ADL's) for all cares including bathing, dressing, and hygiene. R71's facesheet printed 2/15/24 at 4:50 p.m., indicated R71's Emergency Contact #1, Responsible Party, and Guardian was FM-A. R71's progress note (PN) documented with Effective date of 1/29/24 at 8:49 p.m., indicated R71, pulled the G-tube. The resident [sic] called the NP, instructed to put on a folly [sic] and send the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · Dcited before2024-02-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a potential allegation of mental or emotional abuse was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R77) reviewed who reported being bothered and potentially harassed by another resident. Findings include: R77's quarterly Minimum Data Set (MDS), dated [DATE], identified R77 had intact cognition but did not speak English as their primary language with use of an interpreter to communicate with healthcare staff preferred. R77's care plan, last reviewed 1/17/24, identified R77 had impaired mobility and used a wheelchair to reach all destinations. The care plan outlined, [R77] have impaired cognitive function. BIMS [brief interview for mental status] score varies 11/15 to 14/15 [moderate impairment to cognitively intact], and directed to use R77's family member (FM) to help interpret as needed. The care plan indicated R77 had a communication-barrier but added, Knows some English. Further, the care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0645 — isolatedPASARR 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 a Level I pre-admission screening (PAS) was clarified or acted upon in a timely manner to determine what, if any, additional evaluation or screenings (i.e., Level II) were needed for 1 of 2 residents (R75) reviewed for pre-admission screening and resident review (PASARR). Findings include: R75's significant change Minimum Data Set (MDS), dated [DATE], identified R75 had intact cognition along with several medical conditions including Bipolar Disorder; however, R75 did not have a current dementia or Alzheimer's Disease diagnosis. In addition, R75's Medical Diagnosis, contained in their electronic medical record (EMR), listed all of R75's current medical conditions with a corresponding effective date. This listing included, Bipolar Disorder, Unspecified, with an effective date of 10/2022. R75's initial Minnesota Senior Linkage Line Preadmission Screening (PAS) Results, dated 10/2022, identified R75 was admitting to the care center from an acute…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and records review, the facility failed to correctly transcribe and administer an ordered medication for 1 of 1 residents (R11) reviewed for quality of care. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R11 had intact cognition and was diagnosed with heart failure, kidney failure, respiratory failure, and chronic obstructive pulmonary disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). The MDS indicated R11 was receiving oxygen therapy and hospice care but indicated R11 did not demonstrate shortness of breath during the look-back period. The MDS indicated R11 required moderate assistance with dressing, supervision with transferring, and was independent with eating. R11's care plan dated 9/11/23, indicated R11 received hospice care related to her diagnosis of COPD. The care plan indicated R11 had an alteration in respiratory status related to COPD, heart failure, and dyspnea (shortness 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.
- Potential for harm · D2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation, interview and records review, the facility failed to ensure controlled medications were properly recorded, stored and secured to prevent and minimize the risk of diversion for 1 of 1 residents (R243) reviewed for medication storage. Findings include: R243's admission Minimum Data Set (MDS) was in progress, no information available. R243's admission record dated 2/15/24 indicated R243 was admitted to facility on 2/9/24, with diagnoses of amyotrophic lateral sclerosis (a disease that weakens muscles and impacts physical function), insomnia, quadriplegia (paralysis of all four limbs), sleep apnea, shortness of breath, generalized muscle weakness. R243's progress notes written by nurse practitioner (NP), dated 2/14/24, also indicated diagnoses of chronic lower back pain and glaucoma (eye condition that causes blindness). R243's admission orders dated 2/9/24 included orders for 1-2 tablets of tramadol (a controlled medication) 50-100 milligrams (mg) by mouth twice a day as needed for eszopiclone (medication used for inability to sleep and a controlled medication) 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-02-15 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
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 resident mail was delivered on Saturdays for 3 of 3 residents (R17, R20, R29) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 94 residents residing in the facility. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], indicated R17 had resided at the facility for over one year and had no cognitive impairment. R20's quarterly MDS dated [DATE], indicated R20 had resided at the facility for over one year and had no cognitive impairment. R29's quarterly MDS dated [DATE], indicated R29 had resided at the facility for over one year and had no cognitive impairment. During an interview on 2/14/23 at 10:43 a.m., R20 stated he never got his mail on Saturdays and sometimes it would take until Tuesday to get his mail. R20 then stated that it bothered him that this kept happening. During the same interview, R29 stated that she had also not been receiving her mail on Saturdays 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.
- No harm found · C2024-02-15 · tag F0732 — widespreadPost 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 the required nurse staffing information was posted daily and retained for 18 months. This had the potential to affect all 94 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation, document review, and interview on 2/12/24 at 12:11 p.m., the nursing staff posting was observed in the main lobby near the entrance and was dated 2/9/24 with a resident population of 96. During interview, administrator stated the staffing coordinator (SC) was in charge of updating the staff posting but it had not been completed yet today. During an interview on 2/13/24 at 2:44 p.m., the director of nursing (DON) stated that he and the SC worked jointly to address staffing needs and required posting information. The DON stated that he was unaware of the requirement to retain previous staff postings and therefore could not produce these. The DON stated he had attempted to print off the previous staff postings from the computer program the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.3 | -0.3 vs chain |
| Health inspection | 4 of 5 | 3.4 | +0.6 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 1 of 5 | 2.8 | -1.8 vs chain |
The other 20 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/30/2005 |
| ANCHOR BANK, N.A | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 07/11/2012 |
| OLD NATIONAL BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 07/11/2012 |
| FLOY, AMY | Individual | W-2 MANAGING EMPLOYEE | — | since 07/03/2021 |
| KURVERS, MADELINE | Individual | W-2 MANAGING EMPLOYEE | — | since 05/23/2022 |
| LARSON, DUANE | Individual | CORPORATE DIRECTOR | — | since 01/01/2020 |
| LINDH, DANIEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/30/2005 |
| MEYER, MARK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/30/2005 |
| PHS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/11/2011 |
CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245462. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.