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Auburn Manor

501 Oak Street, Chaska, MN 55318 · Non profit - Corporation · 60 certified beds · (952) 448-9303 Medicare & Medicaid certified

Call the home — (952) 448-9303 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
822 Yellow Brick Rd · (952) 448-3303 · Call to confirm hours
Pharmacy
3110 Chaska Blvd · (952) 448-1180 · Call to confirm hours
Grocery
Bhale30.1 mi
台灣 · +886943730249 · Call to confirm hours
Park
350 N Chestnut St · (952) 448-3176 · Typically dawn to dusk
Place of worship
401 E 4th St · (952) 448-1755

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 4 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased30.1%18.2%15.4%worse
Long-stay residents who lose too much weight4.7%4.1%5.4%better
Long-stay residents with a catheter left in their bladder6.7%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.4%2.6%2.0%worse
Long-stay residents with depressive symptoms2.4%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.6%4.0%3.3%worse
Long-stay residents whose ability to walk worsened31.9%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.4%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine95.2%96.1%95.3%typical
Long-stay residents with pressure ulcers7.3%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control31.7%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine65.3%82.7%79.4%worse
Short-stay residents rehospitalized after admission21.1%23.5%22.6%typical
Short-stay residents with an outpatient ER visit15.1%14.8%12.0%worse

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.

63.1% 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 62 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.1%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 28 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.1%CMS range 52.3–72.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.5–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge42.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 2.7–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.11
RN hours/ resident / day
0.30
LPN hours/ resident / day
2.41
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.79
RN hoursweekends
41.8%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 44.3 residents a day — about 74% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.11 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 3.97 on weekdays — 13% thinner on weekends. RN hours go from 1.24 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-04-30)
14
at the previous standard inspection (2025-02-06)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2025-04-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 3 residents (R1) physician orders were followed for parameters set by the physician. This resulted in actual harm for R1 who became unresponsive and required emergency transport and hospitalization after receiving insulin that should have been held. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of diabetes mellitus, dementia, and mild cognitive impairment. R1's care plan, dated 9/13/24, directed administer insulin as ordered, monitor for side effects/effectiveness of medication and update provider as needed. Monitor for signs and symptoms of hypoglycemia, follow standing house orders, and update nurse practitioner (NP) as needed. R1's provider orders, dated 3/12/25, directed decrease insulin aspart (rapid-acting insulin used to manage blood sugar in people with diabetes) to 6 units before meals related to Type 2 Diabetes Mellitus with diabetic neuropathy. Hold if blood sugar less than…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-30 · tag F0576 — widespread
    Ensure 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

    Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R33, R34, R14, R24) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility.On 4/30/26 at 9:33 a.m., a Resident Council meeting was held with four residents from varied areas of the facility. R24 stated mail was not delivered to residents on Saturdays. This was confirmed by R33, R34 and R14. R24 indicated mail delivered by the post office on Saturdays would be left on the receptionist's desk near the front entrance. On Monday morning the receptionist would sort and deliver the mail to residents.During interview on 4/30/26 at 1:09 p.m., Secretary (S)-A stated it was her job Monday through Friday to sort and deliver the mail. SA stated on the weekend it would be the responsibility of the nursing supervisor.During interview on 4/30/26 at 1:22 p/m., registered nurse (RN)-A stated she was unaware collecting and passing mail was part of her responsibilities on 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 store and label food properly, dispose of undated and expired food items to reduce the risk of foodborne illness. This had the potential to affect all the residents who were provided meals from the kitchen. Findings include:During initial tour and interview of kitchen on 4/27/26 at 1:03 p.m., with Dietary Director (DD) the following was observed inside the walk-in cooler: an opened box of undated chicken stock an opened box of undated turkey stock an approximately 4x4x8 inch metal dish containing sliced carrots lacked an open or use by date,an approximately 4x4x8 inch metal dish with contents identified by DD as pizza sauce lacked an open or used by date.DD stated he was unsure of what the food storage policy stated in regard to leftover food, but he believed all food was to be dated with both an opened on and use by date.During observation of refrigerator in kitchenette by north nursing station on 4/28/26 at 2:48 p.m., the following…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-30 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide ongoing communication to residents about their rights (e.g., through resident groups) for 4 of 4 residents (R33, R34, R14, R24) who attended the council meetings.Findings include:R33 quarterly minimum data set (MDS) dated [DATE], indicated R33 was cognitively intactR34 quarterly MDS dated [DATE], indicated R34 was cognitively intactR14 quarterly MDS dated [DATE], indicated R14 was cognitively intactR24 quarterly MDS dated [DATE], indicated R24 was cognitively intactResident council meeting minutes dated November 2025 through April 2026, lacked evidence resident rights had been reviewed or included in meeting discussions.During a resident council meeting on 4/30/26 from 9:33 a.m. to 10:48 a.m., R33, R34, R14 and R24 stated they regularly attended resident council meetings and did not recall a time when resident rights had been discussed. All four residents stated they did not know where resident rights were posted in the facility. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 2 (R33, R34) residents reviewed for dignity, received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide toileting assistance resulting in episodes of incontinence.Findings include:R33's admission minimum data set (MDS) dated [DATE], indicated R33 was cognitively intact and had the following diagnoses: history of urinary tract infections (UTI's), depression, generalized weakness and lymphedema (swelling caused by an accumulation of fluid in the tissues).During interview on 4/27/26 at 3:13 p.m., R33 stated she frequently waited for assistance to use the bathroom and at times it could be over an hour. R33 stated it had caused her to become incontinent of both bowel and bladder. She went on to state it doesn't make me feel good. Its degrading. No one wants to sit in their pee or poop.Review of R33's call light logs from 3/29/26 through 4/28/26 indicate R33 had call lights…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 residents were aware how to file grievances anonymously, for 4 of 4 residents (R33, R34, R24, and R14) reviewed for grievances. Further, the facility failed to maintain a grievance log for a minimum of 3 years. This had the potential to affect all residents residing in the facility.Findings include: During the initial entrance conference on 4/27/26 at 12:11 p.m., Director of Nursing (DON) stated there were no grievances for the previous six months. On 4/30/26 at 9:30 a.m., R33, R34, R24, and R14 stated they were unclear how to file an official grievance, or where to find a grievance form to assure anonymity. All four residents stated they could talk to the Director of Nursing (DON). DON had instructed residents all grievances or concerns were to be handled internally. During interview on 04/30/2026 at 1:22 p.m., DON stated a grievance is any report of a concern a resident feels necessary to discuss about their care or about the facility. DON stated if a resident had a concern they were to bring it to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 mediations were administered in accordance with physician orders for 1 of 1 residents (R 24) reviewed for medications administration.Findings include: R24's quarterly minimum data set (MDS) dated [DATE] indicated R24 was cognitively intact and had the following diagnoses: Multiple Sclerosis, Hypertension, Neurogenic bladder, Chronic Obstructive Pulmonary Disease and Hyperlipidemia.During interview on 4/30/26 at 10:48 a.m., R24 stated she had not received her scheduled 7:00 a.m. medications. R24's medication administration record on 4/30/26 at 10:52 a.m., revealed blank boxes for R24's scheduled 7:00 a.m. medications indicating they had not been administered. R24 was scheduled but did not receive the following medications:Glucosamine-Chondroitin 500-400mg tablet- 1 tabLisinopril 20mg -1 tabOmeprazole 20mg -1 capsuleMultivitamin tablet -1 tabTrimethoprim 100mg -1 tabFluticasone-Salmeterol Inhalation Aerosol 250-50 MCG/ACT - 1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 COVID-19 vaccinations were offered to 1 of 5 residents (R6) reviewed for COVID-19 vaccination status.Findings include: R6's quarterly minimum data set (MDS) dated [DATE], indicated R6 was admitted to the facility on [DATE], and had the following diagnoses: high blood pressure, hyperlipidemia (high levels of fat in the blood), and malnutrition. R6's undated client information vaccination record indicated R6 was overdue for their COVID-19 vaccination. R6's medical record lacked any evidence a COVID-19 vaccination was offered or provided. On 4/30/26 at 10:00 a.m., the Infection preventionist (IP) stated they had just started in this role recently. R6 had been on a list of the previous infection preventionist to be completed, however, was unable to find any supportive documentation it was ever offered or completed. The IP stated they would have expected the vaccination to have been completed within a few days of R6's admission and confirmed it should…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-06 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient nursing staff and leadership to meet assessed resident needs and facility processes for 2 of 2 residents (R5, R37) reviewed for pressure ulcer prevention, for R7, R42 reviewed for activities of daily living who were dependent on staff for their care, for R1 who was left exposed and nude on the toilet, and R18 who utilized an indwelling catheter reviewed for dignity. In addition, the facility failed to reassess and implement proactive interventions to reduce the risk of falls and injuries for R26 and R44 who sustained falls at the facility. Additionally, the facility failed to address ongoing staffing and long call light concerns identified during resident council meeting minutes. Also, during survey, one family (FM-A) and four residents (R4, R5, R14, and R33) expressed ongoing concerns with not enough staff and significant wait times for cares. These findings contributed to several associated deficiencies and the lack…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview and policy review, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in 3 of 5 medication carts affecting 3 of 4 units of the facility. Findings include: During observation on 2/03/25 at 7:36 p.m., an unattended and unlocked medication cart was observed outside in the hallway of the unit named, Eagle Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. At 7:40 p.m., registered nurse (RN)-E returned to medication cart. RN-E indicated they left the medication cart unlocked and unattended. RN-E stated a resident was hollering and they went to help them. RN-E stated it unattended medication carts should always be locked so residents couldn't get into it. During a continual observation on 2/05/25 at 11:08 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Bluejay Lane. The cart was placed between the doors of resident rooms.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet while facing a window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE] identified R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. In addition, R1 had diagnoses of spinal stenosis (narrowed space around the spinal cord causing irritation and compression of the spinal cord), heart failure, and arthritis. During observation on 2/4/25 at 8:08 a.m., R1 was sitting on the toilet naked. R1 was left alone by nursing assistant (NA)-C while NA-C left room to obtain supplies. The bathroom had a shower curtain as…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2025-02-06 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R30) reviewed whose Medicare Part A coverage ended and they remained in the facility. Findings include: R30's Notice of Medicare Non-Coverage (CMS-10123) dated 10/22/24, indicated R30's last covered day of Medicare A would be 10/22/24, and was signed by family member (FM)-B on 10/17/24. R30's SNF Beneficiary Protection Notification Review form dated 10/22/24, indicated R30 had not been provided a SNFABN as resident won appeal. R30's Notice of Medicare Non-Coverage (CMS-10123) dated 11/7/24, identified R30's last covered day of Medicare A would be 11/7/24, and was signed by family member (FM)-B on 11/4/24. R30's Census record dated 2/1/25, indicated R30's primary payer source switched from Medicare A to private pay on 11/8/24, and they stayed in the facility until current. R30's medical record was reviewed and did not indicate a SNFABN had been given prior to R30's Medicare Part A coverage ending. During an interview on 2/4/25…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    During observation and interview, the facility failed to ensure 3 of 3 (R14, R19, R149) resident records that contained private, medical, and personal information were not accessible to unauthorized personnel. Findings include: During observation on 2/3/25 at 7:25 p.m., an unattended laptop identified three residents and their care sheet information. The care sheet information contained their names, diagnoses, assistance needs for dressing and showering, oxygen status, diet, toileting, repositioning, and special instructions such as preferences. Two staff walked past the unattended laptop. During interview with nursing assistant (NA)-B on 2/3/25 at 7:29 a.m., NA-B stated, that should not be open for anyone to see. Privacy is why. During interview with NA-A on 2/3/25 at 7:33 p.m., NA-A stated he was responsible for the unattended laptop. NA-A stated unattended laptop contained visible, patient confidentiality [information] and it should not be left open for everyone to see. During interview with Trained Medication Aide (TMA)-A on 2/4/25 at 7:55 a.m., TMA-A pointed to laptop and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs. Findings include: R42's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had intact cognition. R42 required moderate staff assistance with personal hygiene and oral hygiene, maximum assistance from staff for upper body dressing, and was dependent on staff for bed mobility, sit to lying, lying to sitting on side of bed, footwear, lower body dressing and toileting. MDS indicated no behaviors present or rejection of care exhibited. R42's pertinent diagnoses included: displaced intertrochanteric fracture of right femur (a broken hip bone that has shifted or separated), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had severe cognitive impairment but demonstrated no delusional or rejection of care behaviors. Further, the MDS identified R7 was dependent on staff for personal hygiene care. On 2/3/25 at 5:31 p.m., R7 was asked about her baths at the care center. R7 stated aloud, I'm missing those, while making a back and forth motion using her hands. R7 struggled with word-finding but reiterated, when pointedly asked, she was not getting her baths every week adding aloud, Yea [affirm]. R7's care plan, dated 9/16/24, identified R7 had a self-care deficit and needed assistance with ADLs due to weakness and other past medical history or conditions. The plan listed a goal which read,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess potential signs of constipation to determine what, if any, proactive interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R41) who reported being constipated. Findings include: R41's admission Minimum Data Set (MDS), dated [DATE], identified R41 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS identified R41 did not have constipation. On 2/3/25 at 1:51 p.m., R41 was interviewed and stated she had recently moved into the care center from the hospital. R41 stated her bowels were not too good and complained of feeling constipated adding, I get stuffed up a lot. R41 stated staff were aware of this and, when she'd ask, they would give her medication to have a bowel movement. R41 stated she didn't recall anyone ever talking with her about what proactive interventions could be done such as prune juice or fiber supplements. R41…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries. Findings include: R5 R5's annual Minimum Data Set (MDS) dated [DATE] identified R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, R5 was identified as at risk of developing a pressure ulcer/pressure injury. R5's electronic medical record (EMR) nursing assistant task form titled TRANSFER: SELF PERFORMANCE-How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and documented from 1/22/25, to 2/4/25, identified R5 as requiring, TOTAL DEPENDENCE-Full staff performance. R5's EMR nursing assistant task for titled, BED MOBILITY: SUPPORT PROVIDED-How…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed, develop proactive interventions to reduce the risk of further falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center. Findings include: R44 R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). Further, the MDS outlined R44 had sustained a fall within the month prior to admission, however, sustained no falls since she admitted to the care center. R44's care plan, revised 12/20/24, identified R44 was at risk for falls with dictation, NURSING: The resident is at risk for falls [related to] weakness, impaired mobility . [as evidenced by] H/O [history of] fall prior to admission. The plan listed a goal which read, The resident will be free of falls through…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess for entrapment risk and attempt alternatives before installation of grab bars for 1 of 3 residents (R15) reviewed who were observed to have grab bars affixed to their beds. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R15 had moderately impaired cognition and required substantial assistance with transferring out of bed. The MDS indicated in section, P0100. Physical Restraints, that R15 had bed rails that were used as restraints daily. R15's Grab Bar assessment dated [DATE], indicated the assessment was done on the resident's admission to the facility, and bilateral grab bars were used to assist the resident with moving side to side. The assessment included a section Identify alternative methods/products attempted prior to the use of grab bars which was left blank. The assessment indicated the risks and benefits of grab bar use had been explained to R15/her representative…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R44) reviewed for unnecessary medication use. Findings include: R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment but demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care). Further, the MDS identified R44 had depression, anxiety disorder, but consumed only anti-depressant medication (i.e., high-risk medication) during the review period. On 2/5/25 at 8:54 a.m., R44 was observed seated in a standard wheelchair in the television room by the central nursing station. R44 appeared calm and responded aloud, Good, when asked about her day so far. R44 was unsure how long she had lived at the care center and responded again aloud, Pretty good. R44 had no obvious…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R37) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R37's quarterly Minimum Data Set (MDS), dated [DATE], identified R37 admitted to the care center in August 2024, and had several medical conditions including dementia…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-31 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement, and failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 50 residents which resided in the facility. Findings include: Refer to F883 During document review, the quality assurance and performance improvement (QAPI) quarterly meeting minutes for 7/26/23, 1/30/24, 4/23/24, all indicate a section titled survey results and plan of correction (POC), with an agenda item, survey between 3/27 - 3/30/23 Results: Issues with Pharmacy Review, PPSC 23/PCV13/ Influenza vaccinations, COVID Vaccine Information Sheets, Vaccination offerings and Policy and TB testing. During an interview with the direction of nursing…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-31 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 adhere to evidence based practices and assure resident catheter bags & ports were maintained in an appropriately placement for 2 of 2 resident (R7 & R146) whos catheter bags were on the the ground. The facility failed to ensure proper personal protective equipment (PPE) & hand hygiene was used for 2 of 2 residents (R146, R198) when providing care for residents on enhanced barrier precautions (EBP) & contact precautions. Furthermore the facility failed to identify and track potential infections for 1 of 1 resident (R198) reviewed for antibiotics use. Additionally, the facility failed to develop a written policy/procedure of infection surveillance and maintain a policy, procedure or water management plan to reduce the likelihood of Legionella and other serious bacterial diseases, which had the potential to affect all 50 residents. Findings Include: ENHANCED BARRIER, CONTACT PRECAUTIONS AND HAND HYGIENE R198's admission Minimum Data Set…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-31 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    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 and implement a facility wide system to monitor the use of antibiotics and reduce unnecessary or inappropriate antibiotic use, which reduces risk of adverse effects, for 1 of 1 resident (R198) reviewed for antibiotic use. This had the potential to affect all 50 residents residing in the facility. Findings include: R198's face sheet undated, indicated R198 had diagnoses which included diarrhea, a stage 3 pressure ulcer (a wound that breaks down skin and underlying tissue) of the sacral (tailbone) region, unspecified stage pressure ulcer to the left buttock, muscle weakness, depression, and anxiety. The face sheet also indicated the resident admitted to the facility on [DATE]. R198's order summary included the following orders: - Monitor resident for loose watery stools and update provider as needed every shift, dated 5/28/24. - stool culture for Clostridium difficile (bacteria that can cause inflammation of the colon and severe diarrhea, often…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure privacy was maintained for 1 of 2 residents (R146) reviewed for dignity. Findings include: R146's face sheet undated, indicated R146 admitted [DATE] and had diagnoses of nondisplaced intertrochanteric fracture of right femur, unspecified fall, weakness, essential tremor, and depression. R146's baseline care plan observation dated 5/28/24, identified R146 was oriented to person and time and had forgetfulness and intermittent confusion. R146 required assistance of one with bed mobility, toileting, dressing, and grooming/hygiene. R146 transferred with a standing mechanical device with assistance of two and did not walk. R146 had a history of falls with fracture prior to admission and was incontinent of bladder and bowel. R146's paper baseline care plan dated 5/28/24, identified R146 had a foley catheter and occasional, accidental incontinence. During observation on 5/30/24 at 8:59 a.m., nursing assistant (NA)-B uncovered R146, stated R146 had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents were free from accident hazards for 1 of 1 residents (R13) who used a remote-controlled recliner. In addition the faility failed to comprehensively assess resident falls to ensure appropriate interventions were implemented to reduce the risk of falls for 2 of 4 residents (R13, R99) reviewed for falls. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment with no exhibited verbal or physical behaviors, no rejection of care, and no hallucinations or delusions. The MDS also indicated R13 had hemiplegia and hemiparesis (one-sided weakness and immobility) due to a stroke, depression, high blood pressure, and restless leg syndrome. R13's Care Area Assessment (CAA) dated 8/4/23, for functional status indicated he had right-sided weakness from a stroke with decrease range of motion to the affected side. The CAA indicated R13 had reached his baseline and declined restorative…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-31 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent, and attempt alternatives prior to installation of grab bars for 2 of 2 residents (R96, R146) reviewed who were observed to have grab bars affixed to their beds. Findings include: R96's admission Minimum Data Set (MDS) dated [DATE], indicated they were severely cognitively impaired, required partial/moderate assistance with bed mobility and transfers, and had diagnoses of fractures, heart failure, and anxiety. The MDS indicated R96 did not use a bed rail. R96's admission Observation Detail Report dated 5/7/24, included R96 required extensive assistance of one staff for transfers, was occasionally incontinent of bladder and bowel, had a fall in the previous 31-180 days, and did not use bed rails. R96's progress note dated 5/7/24, indicated staff completed admission paperwork with R96's family member and power of attorney, however, the note lacked evidence 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-31 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure dishware was maintained in a safe and sanitary manner by failing to remove chipped and cracked dishware from use within the facility. Findings include: During interview on 5/31/24 at 7:48 a.m., an unidentified resident stated the facility had a lot of chipped ceramic dishware, including bowls and cups. They stated they had sent them back and let the staff know, it bothered them, and they would not want to use chipped and cracked dishes at home, however the facility had not corrected the concern. During observation on 5/30/24 from 8:05 a.m., - 8:36 a.m., a.m., three bowls containing various amounts of leftover oatmeal were observed on the tables in the dining room after the residents finished breakfast, each with at least one chip in the outer lip of the bowl, exposing the material under the glossy coating. One nursing assistant was assisting a resident to eat oatmeal from another chipped bowl. One additional chipped bowl was in the clean pile to be used for the next resident who requested oatmeal.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-02-06 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded to reflect actual restraint use for 4 of 4 residents (R2, R15, R26, R41) reviewed for MDS accuracy. In addition, the facility failed to accurately complete a Brief Interview for Mental Status (BIMS) assessment for 1 of 4 residents (R17) reviewed for MDS accuracy. Findings include: Restraint Use The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, outlined a section labeled, SECTION P: RESTRAINTS AND ALARMS, which directed to record the frequency a resident was restrained by any of the listed devices during the seven-day look-back period. A definition of physical restraint was provided which outlined, Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts…

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

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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BATTIS, STEVENIndividualCORPORATE DIRECTORsince 01/22/2013
BUEMER, DALEIndividualCORPORATE DIRECTORsince 01/25/2018
DETTMAN, SCOTTIndividualCORPORATE DIRECTORsince 03/01/2023
FISCHER, TODDIndividualCORPORATE DIRECTORsince 03/01/2023
HEROUX, STEVENIndividualCORPORATE DIRECTORsince 03/01/2023
HOKENESS, DANIELIndividualCORPORATE DIRECTORsince 01/23/2014
KOHLHOFF, KEVINIndividualCORPORATE DIRECTORsince 09/01/2023
KONKOL, DENNISIndividualCORPORATE DIRECTORsince 10/01/2024
MEIDENBAUER, ROBERTIndividualCORPORATE DIRECTORsince 03/01/2023
SANDAU, JILLIndividualCORPORATE DIRECTORsince 01/22/2016
WAGNER, LYNNEIndividualCORPORATE DIRECTORsince 10/01/2024
ZWART, ARVINIndividualCORPORATE DIRECTORsince 01/01/2009
MARKS, JULIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/09/2025
MAUTHE, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/29/2023
SHOGER, BRUCEIndividualCORPORATE OFFICERsince 11/15/2012
ILLUMINUS INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/29/2023
MORAVIAN CARE MINISTRIESOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/10/1993
HALL, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2025
JOHNSON, CHRISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020

CMS files one row per role, so the 26 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 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.

$7.1M
Net patient revenuemost recent cost report
-7.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 50%Medicare 7%Other / private 44%

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

$442per resident / day
operating cost
$13,445per month
≈ monthly operating cost
$413per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245604. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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