Saint Therese At Oxbow Lake
9751 Regent Avenue North, Brooklyn Park, MN 55443 · Non profit - Corporation · 64 certified beds · (763) 493-7007 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 14.1% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.6% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.6% | 4.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.7% | 4.0% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 5.4% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.1% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.9% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.1% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.4% | 14.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.24 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.98 | 1.90 | 1.80 | 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.
70.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 259 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.4% 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 118 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% 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
| 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 | 70.0%CMS range 64.4–74.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.7–13.9 | 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 | 75.4% | 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 | 72.9% | 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 | 70.3% | 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 | 99.2% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 0.0% | 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 | 5.2%CMS range 3.1–9.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 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 64 beds and averages 59.7 residents a day — about 93% occupied, or roughly 4 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 4.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.24 hrs/resident/day on weekends vs 4.92 on weekdays — 14% thinner on weekends. RN hours go from 2.21 to 1.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · E2026-02-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure care plans were revised for 6 of 14 residents (R5, R8, R10, R40, R47 and R7) whose care plans were reviewed for accuracy.Findings include: R5 R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and required assistance with all activities of daily living (ADLs). R5's diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, hypertension (high blood pressure), diabetes mellitus (high blood sugar due to impaired insulin regulation), arthritis (joint inflammation causing pain and stiffness), other fractures (history of bone fractures), anxiety disorder (excessive worry or fear), depression (persistent feelings of sadness), metabolic encephalopathy (altered brain function due to metabolic imbalance) and paroxysmal atrial fibrillation (intermittent irregular heart rhythm). The MDS indicated R5 had experienced one fall with a major injury and was dependent will all transfers. R5's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-26 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, record review, and interview, the facility failed to ensure residents received an ongoing program of activities designed to meet their assessed needs, interests, and abilities in accordance with their comprehensive care plans for 4 of 5 residents reviewed for activities (R6, R10, R13, and R42).Findings include:R6R6's quarterly Minimum Data Set (MDS), dated [DATE], identified R6 had intact cognition. R6's diagnoses included arthritis (joint inflammation causing pain and stiffness), macular degeneration (loss of central vision), overactive bladder (frequent or urgent need to urinate), cervicalgia (neck pain) and sensorineural hearing loss - bilateral (permanent hearing loss in both ears). Observations of R6 were conducted on multiple occasions during the survey:On 2/23/26 at 11:14 a.m., R6 was observed sitting in her recliner with her legs elevated, eyes closed, and mouth open. No activity materials or staff interaction were present.On 2/24/26 at 11:39 a.m., R6 was observed sitting in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · 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, the facility failed to ensure a resident was treated with dignity and respect by maintaining privacy of a urinary catheter drainage bag, resulting in the visible exposure of urine to others passing by for 1 of 1 resident observed (R10).Findings include: R10's annual Minimum Data Set (MDS), dated [DATE], identified R10 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R10's diagnoses included stroke (a condition in which blood flow to the brain is interrupted or reduced causing brain cell damage), atrial fibrillation (an irregular and often rapid heart rhythm that can increase the risk of stroke and heart-related complications), heart failure (a chronic condition in which the heart is unable to pump blood effectively), hypertension (chronically elevated blood pressure), peripheral vascular disease (a circulatory disorder that causes narrowing or blockage of blood vessels outside of the heart and brain), gastroesophageal reflux…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0553 — failed to let residents help plan their care — isolatedAllow 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided the opportunity to participate in the planning of their care through timely care conferences for 2 of 7 residents reviewed for care planning (R8 and R19).Findings include:R8R8's quarterly Minimum Data Set (MDS) dated [DATE] identified R8 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R8's diagnoses included non-traumatic brain dysfunction (impaired brain function affecting cognition or behavior not caused by physical injury); vascular dementia - severe - without behavioral, psychological, mood, or anxiety disturbances (advanced cognitive decline caused by impaired blood flow to the brain); hypertension (chronically elevated blood pressure); arthritis (joint inflammation causing pain and reduced mobility); chronic obstructive pulmonary disease (COPD) (chronic lung disease causing airflow limitation and breathing difficulty); paroxysmal atrial fibrillation (intermittent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure discharge against medical advice (AMA) was documented for 1 of 1 residents (R76) reviewed for discharge. R76's entry minimum data set (MDS) dated [DATE], indicated R76 admitted to the facility on [DATE]. R76 admitted from a hospital stay. R76's discharge MDS dated [DATE], indicated R76 had an unplanned discharge. R76 had diagnoses that included lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Progress note dated 12/18/25, at 2:10 p.m. indicated R76 admitted to facility following hospitalization. Progress note dated 12/18/25, at 7:06 p.m. indicated R76 had gotten agitated and physically aggressive towards staff. Staff attempted to redirect but unsuccessful. Resident was noted attempting unsafe self-transfers. An electronic medical record (EMR) Medication administration note dated 12/18/25, at 8:44 p.m. indicated R76 left AMA. Review of R76's progress noted and documents in the EMR on 2/25/26,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0628 — isolatedProvide 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 send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 2 residents (R76) reviewed for discharge. R76's entry minimum data set (MDS) dated [DATE], indicated R76 admitted to the facility on [DATE], R76 admitted from a hospital stay. R76's discharge MDS dated [DATE], indicated R76 had an unplanned discharge. R76 had diagnoses that included lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Review of the December 2025 and January 2026 Ombudsman notifications sent by the facility failed to indicate Ombudsman office was notified R76 had discharged from the facility. Review of R76's electronic medical record (EMR), indicated R76 was not administered evening medications on 12/18/25, due to having discharged against medical advice (AMA). When interviewed on 2/26/26 at 1:00 p.m., social worker (SW)-B stated Ombudsman notifications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's comprehensive care plan was individualized and resident-specific for 1 of 1 resident (R19) reviewed for behavioral care planning.Findings include:R19R19's quarterly Minimum Data Set (MDS), dated [DATE], identified R19 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R19's diagnoses included non-traumatic brain dysfunction (impaired brain function affecting cognition or behavior not caused by physical injury), Alzheimer's disease (a progressive neurodegenerative disorder that causes memory loss, impaired thinking, and decline in functional abilities), heart failure (a chronic condition in which the heart is unable to pump blood effectively to meet the body's needs), hypertension (chronically elevated blood pressure), obstructive uropathy (blockage of urine flow that can impair kidney and bladder function), diabetes mellitus (a metabolic disorder characterized by elevated blood glucose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, record review and interview the facility failed to ensure residents who were dependent on others for activities of daily living (ADLs) received the services needed. This affected 1 of 3 residents (R65) observed for partial bathing and nail care and 1 of 3 residents (R47) observed for facial shaving.Findings include: R65 R65's annual MDS dated [DATE], indicated R65 was dependent on staff for personal hygiene, oral cares, bathing and all other ADLs. R65 had severe cognitive impairment. R65's care plan with revision date 2/16/26, indicated R65 required total assistance of one staff for bathing and oral cares, extensive assistance of one staff for dressing and hygiene/grooming tasks. R65's face sheet printed 2/26/26, indicated R65's diagnoses included dementia, anxiety, hypertension, chronic pain insomnia and major depression. During observation on 2/23/26 at 1:52 p.m., R65 had long fingernails with an unknown, dark brown/black substance under the nails. During observation on 2/24/26 at 2:56…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · 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, record review and interview the facility failed to identify, assess and monitor a new skin concern for 1 of 1 resident (R47) observed for quality of care. Additionally the facility failed to ensure care and services were provided in accordance with professional standards of practice to prevent avoidable harm when assisting a resident with mobility for 1 of 1 resident (R19) observed for wheelchair mobility. Findings include: R47 R47's annual MDS dated [DATE], indicated R47 was dependent on staff for eating, oral hygiene and all other ADLs. R47 had moderate cognitive impairment. R47's physician orders last signed 1/6/26, included, Nurse to complete the Skin Assessment. This order was scheduled weekly on R47's bath day. R47's care plan revision date 1/29/26, failed to instruct staff to observe skin as well as who to report concerns to. No interventions were noted regarding R47's right thumb. R47's face sheet printed 2/26/26 indicated R47's diagnoses included dementia, insomnia, type 2 diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure interventions identified in the comprehensive care plan were implemented to prevent the recurrence of pressure ulcers for 1 of 3 residents reviewed for pressure ulcer prevention (R6).Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and required assistance with all activities of daily living (ADLs). R6's diagnoses included type 2 diabetes mellitus with diabetic neuropathy (high blood sugar causing nerve damage) and arthritis (joint inflammation causing pain and stiffness), Review of R6's electronic medical record (EMR) indicated R6 previously had a stage three pressure ulcer (full-thickness skin loss where fat tissue may be visible) on the left heel which was documented as healed as of 1/23/26. The EMR identified R6 remained at risk for skin breakdown and recurrence of a pressure ulcer. Review of R6's comprehensive care plan printed 2/25/26, included interventions to prevent recurrence 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.
Show the remaining 20 citations
- Potential for harm · D2026-02-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to following therapy recommended ambulation program for 1 of 1 resident (R40) reviewed with scheduled ambulation assistance. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40's cognition was intact and required supervision or touch assist for ambulation. R40 did not participate in a restorative nursing program. R40's care plan with edit date of 9/2/25, included ambulation recommendation for R40 to ambulate to meals with staff assistance with front wheeled walker. Additional instruction included, supervision- nursing ambulation program with support of front wheeled walker to and from all meals with supervision assistance daily. Can also provide walking assistant with restroom use. R40's nursing progress notes reviewed 1/28/25 through 2/25/26, no notes found to indicate R40 refused when staff offered assistance. R40's face sheet printed 2/26/26, indicated diagnoses included ataxia (poor muscle control),…
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 before2026-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, interview and observation, the facility failed to ensure a root cause analysis was completed after a fall to determine interventions to prevent falls, and failed to continue to assess for changes after a head injury per policy, for 1 of 3 (R5) residents reviewed for falls.Findings include:R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment was dependent on staff for all activities of daily living (ADLs) including transfers and bed mobility. R5's diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, hypertension (high blood pressure), diabetes mellitus (high blood sugar due to impaired insulin regulation), arthritis (joint inflammation causing pain and stiffness), other fractures (history of bone fractures), anxiety disorder (excessive worry or fear), depression (persistent feelings of sadness), metabolic encephalopathy (altered brain function due to metabolic imbalance) and paroxysmal atrial fibrillation (intermittent…
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 before2026-02-26 · 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
Based on observation, record review and interview the facility failed to ensure appropriate infection control practices were followed for 1 of 1 resident (R25) reviewed who was diagnosed with COVID and received an aerosol breathing treatment. Findings include:R25's face sheet printed 2/26/26 included diagnosis COVID-19 (2/18/26)During observation and interview on 2/25/26 at 8:30 a.m., licensed practical nurse (LPN)-A explained she needed to assist R25 with a nebulizer treatment. LPN-A entered R25's room after donning appropriate personal protective equipment (PPE), LPN-A left R25's room door fully open. LPN-A set up the nebulizer, applied the face mask to R25 and turned the machine on. At 8:41 a.m., LPN-A turned off the nebulizer machine, cleaned the face mask and medication container with water, then placed on a towel on the counter in R25's room. LPN-A left R25's room and appropriately removed PPE. During interview on 2/25/26 at 9:36 a.m., LPN-A stated not being aware of special instructions when administering aerosol breathing treatments (i.e. nebulizer) to a resident diagnosed…
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 before2026-02-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of the 5 residents (R5) reviewed for immunizations was offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received no prior pneumococcal vaccine should receive PCV20 or PCV21, those who had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R5's face sheet dated 2/25/26, indicated R5 was [AGE] years old. The immunization…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-06 · tag F0578 — failed to honor advance directives / code status — widespreadHonor 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
Based on interview and document review, the facility failed to ensure resident-specific resuscitation wishes, based on a signed Physician Orders for Life Sustaining Treatment (POLST, a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest), were accurately reflected throughout the electronic medical record (EMR) for 1 of 2 residents (R63) reviewed for advanced directives. Additionally, the facility failed to have and follow policies and procedures for implementing advance directives. This had the ability to affect all 60 residents residing in the facility. Findings include: R63's Death in facility tracking record dated 9/28/24, indicated R63 passed away in the facility on 9/28/24. R63's care plan, dated 9/6/24, indicated she had completed a POLST and her wishes would be followed and respected. The care plan directed staff to see her orders for current resuscitation orders. R63's record was selected for closed record review. Her EMR was reviewed on 12/4/24 at 4:00 p.m., and her POLST signed and dated, 7/16/24, 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 · F2024-12-06 · 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 cool meat at temperatures and timeframes to reduce bacterial growth, which had potential to affect all residents, staff, and visitors who consumed food from the main kitchen. In addition, the facility failed to serve food in a manner to prevent contamination and failed to ensure the second-floor ice and water dispensing machine was clean and free of excess mineral build up, which had potential to affect all residents, staff, and visitors who consumed food and ice and/or water from the second-floor kitchen area. Further, the facility failed to ensure a high temperature dish machine was reaching proper rinse temperatures and failed to ensure dietary staff followed appropriate infection control technique while washing and drying dishes, which had potential to affect all residents, staff, and visitors who consumed food on dishes from the first floor kitchen between the transitional care unit and memory care. Findings include: MEAT COOLING…
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 · D2024-12-06 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow resident to safely administer their own medications for 1 of 1 resident (R9) observed with medications at bedside. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact, and had diagnoses of encounter for palliative care, depression, hypertension, renal disease, and lymphedema (chronic condition characterized by swelling when the body is unable to drain extra fluid from tissues). R9 required partial/moderate to substantial/maximal assistance with most activities of daily living (ADLs). R9's admission Record printed and received from the facility on 12/9/24, indicated R9 had further diagnoses of diabetes mellitus with diabetic neuropathy (diabetic neuropathy is nerve damage caused by diabetes), arthritis (group of conditions which cause inflammation of the joints), and osteoarthritis (degenerative joint…
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 · D2024-12-06 · 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
Based on observation, interview, and document review, the facility failed to ensure a resident call light was within reach for 1 of 4 residents (R115) reviewed for call lights within reach. Findings include: R115's admission Record dated 12/6/24, indicated admission date of 12/1/24, and diagnoses included aftercare following joint replacement surgery, unilateral primary osteoarthritis of the left knee, and chronic kidney disease. R115's activities of daily living (ADL) care plan dated 12/1/24, indicated R115 had an ADL deficit related to left total knee replacement and required extensive assistance of one staff for boosting, bed mobility, and dressing, and a standing lift with assistance of two staff for transfers. R115's fall risk care plan dated 12/1/24, indicated R115 was at risk for a fall related to injury due to a history of previous falls and included the intervention to keep call light within reach before exiting the room. During observation and interview on 12/4/24 at 8:30 a.m., R115 was laying in bed reaching toward the right side of the bed. The bed was in a low position,…
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 before2024-12-06 · 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 follow contact precautions and perform evidence-based hand hygiene to reduce the spread of clostridium difficile (C. diff, a highly contagious bacterium that causes diarrhea) for 1 of 1 residents (R164) reviewed for transmission-based precautions (TBP). In addition, the facility failed to ensure proper hand hygiene and glove use was utilized for 1 of 2 residents (R14) observed during personal cares. Furthermore, the facility failed to ensure infection control policies were reviewed on an annual basis. This had the potential to affect all 60 residents residing in the facility. Findings include: R164 R164's admission Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition, was always continent of her bowels, and had diagnoses of right hip fracture (break), weakness, constipation, and nausea with vomiting. R164's Care Area Assessment (CAA) for functional abilities dated 11/21/24, indicated she had activities 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 · Dcited before2024-12-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 3 of 5 residents (R9, R20, R30) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccination recommendations. Additionally, the facility failed to ensure 1 of 5 residents (R30) was offered and/or provided updated vaccinations for influenza disease. Findings include: R9's admission Record printed 12/9/24, indicated he was admitted on [DATE], and was currently [AGE] years old with diagnoses that increased the risk of pneumococcal disease including chronic kidney disease and end stage kidney disease. R9's undated Immunizations tab in PointClickCare (PCC - the electronic medical record) reviewed 12/3/24 at 1:48 p.m., identified the PCV-13 was administered on 3/3/22. R9's vaccine informed consent form dated 10/10/24, reflected he previously received a pneumonia vaccine but lacked consent or declination of further doses. The CDC's PneumoRecs VaxAdvisor for Vaccine…
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 · D2024-10-11 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 residents with food allergies were not served allergens for 1 out of 3 residents (R1) reviewed for accuracy of diets. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had diagnoses of hip and knee replacement. R1's care plan dated 9/18/24 indicated R1 had an allergy to cinnamon. R1's Breakfast meal ticket dated 10/10/24 indicated Allergens: cinnamon, bread choice: cinnamon raisin bread. The diet ticket also indicated: No cinnamon. On 10/9/24 at 4:03 p.m., R1 stated she frequently received items containing cinnamon, which she was allergic to. She was served a snickerdoodle cookie for lunch earlier on 10/9/24. She only ate one bite of the cookie. She was unaware the cookie contained cinnamon until she ate a bite of it. Her reaction to cinnamon was tongue swelling. On 10/10/24 at 8:56 a.m., R1 was observed to have breakfast served to her room, containing bacon, eggs, fried potatoes, with two pieces…
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 · D2024-08-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a person-centered baseline care plan upon admission, and failed to assess, revise and implement new fall interventions for 3 of 3 residents (R1, R2, and R3) who admitted with fall risks and sustained falls after admission. Findings include: See CMS-2567 F689 for additional details. R1: R1's face sheet identified R1 admitted on [DATE] from the hospital. R1's primary diagnosis was a left femur (upper leg bone) fracture. In addition, R1 was diagnosed with neuropathy (condition impacting nerves), atrial fibrillation (Afib - irregular heartbeat), and a history of falls. A hospital Acute Physical Therapy (PT) Evaluation, dated 7/24/24, identified R1 was oriented only to herself and was an unreliable historian. She required one-step commands, increased time to follow the commands, and required repetition of them. PT evaluation additionally indicated R1 required verbal cues for safety, displayed limited to no clearance of her right foot from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess fall risk and implement individualized fall interventions to reduce the risk of falls for 3 of 3 residents (R1, R2, R3) reviewed for accidents. Findings include: R1: R1's face sheet identified R1 admitted on [DATE] from the hospital. R1's primary diagnosis was a left femur (upper leg bone) fracture. In addition, R1 was diagnosed with neuropathy (condition impacting nerves), atrial fibrillation (Afib - irregular heartbeat), and a history of falls. A hospital Acute Physical Therapy (PT) Evaluation, dated 7/24/24, identified R1 was oriented only to herself and was an unreliable historian. She required one-step commands, increased time to follow the commands, and required repetition of them. PT evaluation additionally indicated R1 required verbal cues for safety, displayed limited to no clearance of her right foot from the ground which produced a shuffled, unsteady gait, and had decreased balance, strength, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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 resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 4 residents (R3) reviewed for advanced directives. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact and had diagnoses of heart failure, high blood pressure, and kidney failure. R3's Interagency Orders Form (admission orders) dated [DATE], indicated R3 was discharged to the transitional care unit at the facility after having a right hip replacement. R3's resuscitation status was identified as full code, indicating they wished to have cardiopulmonary resuscitation (CPR) in the event they had no pulse and/or stopped breathing. R3's Provider Orders for Life-Sustaining Treatment (POLST) completed [DATE], signed by R3 (undated) and signed by R3's provider on [DATE], indicated R3 wished to be DNR (do not resuscitate - did not want CPR if they had no pulse and were not breathing.)…
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 before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to implement current fall interventions and develop immediate fall interventions to decrease the risk of additional falls for 1 of 1 resident (R5) reviewed for falls. Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE], indicated R5 had severe cognitive impairment but was usually understood and sometimes understands others. R5 required substantial/maximal assistance with dressing, footwear, toileting hygiene, and transfers. R5 required partial/moderate to substantial/maximal assistance with bed mobility and did not refuse cares R5's diagnosis included diabetes mellitus, dementia, hypertension, coronary artery disease, and renal insufficiency, renal failure, or end-stage renal disease. The MDS indicated R5 received hospice services. R5's Care Area Assessment (CAA) Worksheet undated, indicated falls as a potential problem related to fall history, medications, need for assistance with mobility, incontinence, and recent…
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 · D2024-03-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement interventions to reduce infection for 1 of 1 resident (R47) reviewed for urinary catheter. Findings include: R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 had moderately impaired cognition and required partial/moderate assistance with toileting hygiene, dressing, and transfers. R47 required partial/moderate to substantial/maximal assistance for bed mobility. The MDS indicated R47 had an indwelling catheter. R47's Care Area Assessment (CAA) Worksheet undated, identified R47 had a Foley catheter, required assistance with management, and the care plan identified interventions to avoid complications related to catheter use. R47's indwelling urinary catheter care plan dated 2/23/24, directed staff to change drainage bag to a leg bag in the morning and an overnight bag at bedtime and monitor for signs and symptoms of urinary tract infections, provide catheter cares and report urinary output to the nurse each…
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 · D2024-03-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 observation, interview and document review, the facility failed to ensure pain was managed consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 4 residents (R2, R12, R106) reviewed for pain management. Furthermore, the facility failed to implement non-pharmacological interventions for pain management for 2 of 2 residents (R12 ,R106). R12 R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 had moderately impaired cognition and required partial/moderate assistance for most activities of daily living (ADLs) such as dressing, bed mobility, and transferring. R12's MDS indicated R12 had arthritis (condition with swelling and tenderness of one or more joints) and osteoporosis (condition when bone strength weakens). Further, R12 was on a scheduled pain regimen, had not received any as needed (PRN) pain medications, and received non-medication pain interventions. R12's Pain assessment dated [DATE],…
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 · D2024-03-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure appropriate side effect monitoring was completed related to psychotropic medication use for 1 of 5 residents (R5) and failed to ensure as-needed (PRN) psychotropic medication use was limited to 14 days or had documented rationale for extended use beyond 14 days for 1 of 5 residents (R20) reviewed for unnecessary medications. Findings include: R5 R5's significant change Minimum Data Set (MDS) dated [DATE], indicated he was severely cognitively impaired, and had diagnoses of dementia, depression, stroke, and high blood pressure. R5's Psychotropic Care Area Assessment (CAA) dated 1/15/24, indicated they took antidepressant and sedative/hypnotic medications, had psychiatric or cognitive diagnoses, depression, dementia, and heart disease, and included an overall objective to avoid complications. R5's care plan reviewed 5/2/23, included R5 took psychotropic medication, needed routine monitoring of their dosage, and instructed staff to monitor for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-02-26 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 53 residents currently residing in the facility as well as all staff and visitors.Findings include:During observation on 2/25/26 at 3:45 p.m., displayed by the memory care entrance was the RBOR, year revised 2009.During interview on 2/25/26 at 3:50 p.m. the campus executive director (E stated she was aware of the changes to the [NAME] for assisted living but was not aware of the changes made 12/22/25 to the RBOR.
- No harm found · C2026-02-26 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure facility survey results were posted in an accessible location for residents, staff and visitors. This had the potential to affect all 53 residents residing in the facility as well as staff and visitors. Findings include:During observation on 2/25/26 at 3:40 p.m., a three-ring binder was noted to the left of the front desk, in a clear, plastic holder, screwed to the wall approximately five feet from the floor. The front cover of the binder noted, Survey Results.During interview on 2/25/26 at 3:51 p.m., the administrator stated a resident in a wheelchair or shorter than height at which the binder is currently stored, would not have access to the binder without assistance. Administrator stated, It needs to come down a bit.
“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 SAINT THERESE SENIOR COMMUNITIES — 4 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 | 3 of 5 | 4.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 5 of 5 | 4.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 3 homes this chain runs (chain average 4.0★, 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 |
|---|---|---|---|---|
| SAINT THERESE COMMUNITIES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 06/28/2019 |
| BREMER BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 07/12/2011 |
| ABBOTT, CRAIG | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/23/2022 |
| GILLESPIE, JOSEPH | Individual | CORPORATE DIRECTOR | — | since 08/15/2012 |
| HERB, MARY | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| HOFFMANN, DAVID | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/09/2017 |
| HORSTMANN, STEVEN | Individual | CORPORATE DIRECTOR | — | since 04/01/2020 |
| KRENN, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/01/2011 |
| MCCLUSKEY, PATRICIA | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| MCCROSSAN, JANE | Individual | CORPORATE DIRECTOR | — | since 08/15/2012 |
| MEADS, STEVEN | Individual | CORPORATE DIRECTOR | — | since 03/12/2015 |
| PARMAR, MONA | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| TAFFE, PATRICK | Individual | CORPORATE DIRECTOR | — | since 12/01/2013 |
| WORNSON, KATHRYN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 06/13/2013 |
| SHELANGOSKI, CAL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 03/05/2018 |
| SAINT THERESE | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/28/2019 |
| SAINT THERESE MANAGEMENT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/28/2025 |
| DELANDER, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| MITTAL, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2025 |
| PETERSON, TESSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/10/2024 |
CMS files one row per role, so the 29 rows in the source record cover these 20 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.
About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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. 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245619. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, 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.