Heritage Manor
321 Northeast Sixth Street, Chisholm, MN 55719 · Non profit - Church related · 65 certified beds · (218) 254-5765 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 (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — 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 (1/5)
- its facility-reported quality-measure 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 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 4 to 1 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 | 25.2% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.7% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.6% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.0% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 31.8% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.4% | 12.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 33.5% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.1% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.9% | 23.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.3% | 14.8% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 50 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.1%CMS range 43.0–67.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.7–16.0 | 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 | 64.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.1% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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 65 beds and averages 57.2 residents a day — about 88% occupied, or roughly 8 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.92 hrs/resident/day on weekends vs 3.61 on weekdays — 19% thinner on weekends. RN hours go from 1.15 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% 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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2025-06-26 · 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 interview and document review, the facility failed to track and report lack of bowel movements to provider for 2 of 2 residents (R16, R52) reviewed for bowel tracking. This resulted in actual harm when R16 was hospitalized for constipation and subsequently taken to the operating room for disimpaction. In addition, the facility failed to monitor vital signs and complete weights as ordered for 1 of 1 resident (R52) and follow orders for blood glucose monitoring and insulin administration for 1 of 1 resident (R37).Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 had diagnoses which included osteoarthritis of knee, postconcussional syndrome (a set of symptoms that can persist for weeks, months, or years after a concussion or traumatic brain injury), depression, muscle weakness, trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), constipation, and diabetes. R16's MDS identified R16 was cognitively intact, had impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-06-26 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide 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
Based on observation, interview, and document review, the facility failed to maintain controlled medication accounting for facility stock medication and for 1 of 1 resident (R262) reviewed for medication side effects. The facility failed to ensure residents were free from medication errors for 1 of 1 resident (R262) who didn't receive their medication as ordered. In addition, the facility failed to remove expired facility stock medication which had to potential to affect any resident needing facility stock medication. Findings include: R262's admission Record dated 6/26/25, identified an admission date of 6/17/25 and a diagnosis of irritable bowel syndrome (IBS-D, a condition characterized by stomach pain, cramping and diarrhea).R262 had a provider order dated 6/17/25, for the medication eluxadoline (trade name Viberzi, a schedule IV-controlled substance used to treat IBS-D) oral tablet 75 milligrams (mg) two time per day. Review of R262's medication administration record (MAR) for June 2025, identified the number 9 appeared on 6/19 and 6/25 for the 7 p.m. dose, and on 6/23 for 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 · F2025-06-26 · 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
Based on observation, interview, and document review the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to maintain safe food storage temperatures. This practice had the potential to affect all residents consuming food at the facility. OR Based on observation, interview, and record review, the facility failed to ensure beverages including milk were maintained and served at a safe temperature of less than 41 degrees Fahrenheit (F). In addition, the facility failed to ensure dishwasher temperatures were maintained for proper sanitization of dishes. These deficient practices had the potential to impact all residents residing at the facility Findings include: The facility form Weekly Temp Logs included at the bottom of the form: Temperature danger zone is 41 to 140 F. All food has to be held above or below this until meal service is complete. The breakfast section of the form did not include a section to record beverage temperatures. The lunch and dinner sections had a place to record dessert and milk temperatures.…
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 · E2025-06-26 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure resident call lights were within reach from the bathroom floor in resident bathrooms for 4 of 4 residents (R36, R47, R111, R6) reviewed for call light accessibility.Findings include:During an observation on 6/23/25 at 2:33 p.m., the bathroom call light cord in R6's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 5:31 p.m., the bathroom call light cord in R111's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 6:18 p.m., the bathroom call light cord in R36's room was approximately three feet from the bathroom floor. During an observation on 6/24/25 at 9:14 a.m., the bathroom call light cord in R47's room was approximately three feet from the bathroom floor.On 6/24/25 at 12:08 p.m., maintenance director (M)-A went to each bathroom (405, 407, 410, 413) and verified the call lights were too short, M-A stated the call light cord should be reachable from the floor in case of fall in the bathroom. On 626/25 at 12:48 p.m., 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 · D2025-06-26 · 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, interview and document review the facility failed to get 1 of 2 residents (R36) out of bed when requested.Findings include:R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had diagnoses which included quadriplegia, fracture of surgical neck of left humerus with routine healing, anxiety, and depression. R36's MDS identified R36 was moderately cognitively intact, had no rejections of care, and was dependent on staff for bed to wheelchair transfers. R36's care plan dated 5/21/25, identified R36 had the potential for calling 911 if her call light was not answered fast enough or if she dropped something on the floor. Interventions included to try to answer the call light as soon as possible if not able to answer call light immediately to let R36 know when would be back (to give a length of time). In addition, R36's care plan dated 2/1/25, identified R36 had an activity of daily living (adl) self-care performance and required a mechanical lift with substantial maximal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · 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 interview and record review, the facility failed ensure residents were comprehensively assessed for self-administration of medications for 1 of 2 residents (R20) reviewed for self-administration of medication.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider orders reviewed on 6/25/25, included the following orders:-Advair Diskus inhalation aerosol powder breath activated 250-20 micrograms per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure bathing preferences were honored for 1 of 1 resident (R10) reviewed for choices.Findings include:R10's significant change Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact with the diagnoses of congestive heart failure, diabetes and end stage renal disease. Section GG. indicated R10 required partial/moderate assistance with shower/bathing. R10's Care Plan Report last revised 5/7/25, identified R10 required partial/moderate assistance of one with bathing/showering. R10's care plan lacked identification of R10's preferences for personal hygiene and bathing.During an interview on 6/23/25 at 4:41 p.m., R10 stated they would like to have a shower two times a week. They didn't feel very clean by mid-week and felt like they were smelling a little. They really wished it could be two times a week, but nobody would do it. During an observation on 6/25/25 at 9:03 a.m., R10 was at the nurse station asking when they would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the us of as-needed (PRN) psychotropic medication was limited to 14 days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R20) reviewed for unnecessary medication use.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider order sheet reviewed on 6/25/25, identified order 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.
- Potential for harm · D2025-06-26 · 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 record review the baseline care plan did not cover the required elements for 1 of 2 residents (R110) reviewed for care plans.Findings include:R110's admission Minimum Data Set (MDS) dated [DATE], was in progress. R110 was admitted [DATE]. R110's provider orders dated 6/26/25, identified R110 had diagnoses which included acquired absence of right leg below knee, diabetes mellitus, lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage), and reduced mobility. R110's orders included the following:-Consistency CHO (carbohydrate) diet Regular texture, Thin consistency, limit of potassium to 2000 mg (milligram) dated 6/11/25-Apply Sequential Compression Device to left leg QD (every day) for 1 hour one time a day related to LYMPHEDEMA dated 6/12/25-Observe closely for side effects of Diuretic medication including decreased PO (oral) intake, acute confusion, agitation, delusions, aggression, lethargy, decreased sweating, tachycardia, hypotension, orthostasis,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · 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 observation, interview and record review the facility failed to ensure to develop a comprehensive care plan for 2 of 6 residents (R13, R33) reviewed for care planning. Findings include:R13:R13's admission Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact with the medical condition of fractures and other multiple traumas with the diagnoses of hip fracture and lymphedema. MDS Section N. indicated R13 received opioid pain medication and a diuretic. Section GG. indicated R13 was dependent for showering, toileting, transfers, and required maximal assistance for dressing. R13's care plan date last revised 6/2/25, included the following:ADL self-care performance focus identified R13 required assistance of one with for dressing, oral care, and one to two staff for bed mobility. Personal hygiene and toilet use read I require (specify assistance) by (x) staff for both areas. R13's care plan did not identify nor include focus areas and interventions for hip fracture/weight bearing status,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to revise the care plans to reflect current care needs for 2 of 6 residents (R37, R52) reviewed for care planning. Findings include:R37:R37's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an interview on 6/26/25 at 8:47 a.m., the HUC stated she didn't keep hospice paperwork for St. Croix, any documents they had should be in the hard chart. During an interview on 6/26/25 at 10:20 a.m., the DON would expect there to be a hospice care plan for R37.R52:R52's quarterly MDS dated [DATE], identified limited range of motion (ROM) in both lower extremities. Was dependent on assist of two for toilet…
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 14 citations
- Potential for harm · Dcited before2025-06-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen tubing and supplies were properly managed for 1 of 1 resident (R211) who was reviewed for oxygen use. Findings include: R 211's admit Minimum Data Set (MDS) dated [DATE], indicated R211 was mildly cognitively impaired with the diagnoses of emphysema and congestive heart failure.R211's Care Plan Report last revised 6/8/25, included R211's use of humidified oxygen of 1 to 4 liters related to diagnoses of congestive heart failure and emphysema.R211's Treatment and Medication Administration Record dated between 6/1/25 and 6/24/25, did not include documented oxygen tubing and/or bubbler changes. During an observation on 6/23/25 at 6:48 p.m., R211 was wearing oxygen tubing that was connected to an oxygen concentrator with bubbler (container with water to add moisture to received oxygen). Neither the oxygen tubing or bubbler were dated. R211 stated they were not sure when their oxygen tubing had last been changed.During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 follow dialysis orders for 1 of 1 resident (R111) reviewed for dialysis care. Findings include:R111's admission Minimum Data Set (MDS) dated [DATE], identified R111 had diagnoses which included dissection of thoracoabdominal aorta, anxiety, dependence on renal dialysis, and seizures. In addition, R111's MDS identified she was moderately cognitively intact, had no rejections of care and was receiving dialysis. R111's Order Summary report identified the following:Daily weights, update medical doctor for weight gain more than two pounds per day or five pounds per week. Dated 6/9/25.Ensure the dressing on the double lumen right internal jugular tunneled-site is intact. If comes loose re-secure, or replace dressing with a Tegaderm. Keep dressing clean and dry and lumens covered. Two times a day. Dated 6/9/25.R111's electronic treatment administration record (eTAR) identified the following:Daily weights missing on 6/13/25, 6/16/25, 6/18/25,…
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.
- Potential for harm · D2025-06-26 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medications were administered in accordance with physician orders for 2 of 4 residents (R37, R48) observed to receive medication. A total of three errors out of 34 opportunities were identified resulting in a facility error rate of 8%. Findings include: R37:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus (DM), pneumonia, chronic kidney disease stage three, and chronic gout. R37's medication administration record (MAR) for June 2025, identified an order on 4/2/25 for tart cherry ultra oral capsules 1200 milligrams (mg), give two capsules by mouth two times per day related to gout. During an observation and interview on 6/25/25 at 9:09 a.m., licensed practical nurse (LPN)-E was preparing R37's medications for administration and noted there was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 and interview, the facility failed to maintain the hospice medical record for 1 of 1 resident (R37) reviewed for hospice care. Findings include:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an observation and interview on 6/26/25 at 8:38 a.m., R37's St. Croix Hospice binder was stored at the central nurse's station, it didn't contain any information. R37's hard chart was also stored at the nurse's station, and that chart didn't contain any hospice information. The hospice binder had sections for hospice contact information, admission documentation, charting forms for nursing assistants (NA)s, nurses, and care plans, all of which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to have infection control measures in place for a resident colonized with a multi-drug-resistant bacteria (MDRO, bacteria resistant to one or more classes of antimicrobial agents) for 1 of 1 resident (R41) reviewed for infection control. Findings include: R41's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of obstructive and reflux uropathy, benign prostatic hyperplasia (BPH, non-malignant swelling of the prostate), and extended-spectrum beta-lactamase (ESBL, enzymes produced by certain types of bacteria that make them resistant to many common antibiotics) resistance, and urinary tract infection (UTI). The MDS also indicated R41 was occasionally incontinent of urine and had no catheter or toileting plan. R41's care plan dated 1/31/25, identified an activities of daily living (ADL) self-care performance deficit with interventions to assist with toilet use and hygiene when R41 requested. 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 · F2025-06-26 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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 there were sufficient numbers of staff to ensure all resident cares including getting residents out of bed when requested for 1 of 2 resident (R36) reviewed for choices, monitoring for and treating constipation for 1 of 2 (R16) and monitoring residents receiving dialysis for 1 of 1 resident (R111) reviewed for dialysis care. This had the potential to affect all residents residing in the facility. Findings include:Staff and Resident Interviews/Observations:On 6/23/25 at 2:53 p.m., R110 stated she had taken herself to the bathroom (said she had already waited 40 minutes) and was fearful of soiling self. R110 was tearful during the interview and further stated she had put on her artificial leg on to complete the transfer (even though she had not been cleared by therapy to do so). On 6/24/24 at 8:30 a.m., family member (FM)-F stated therapy had told them at the beginning of May there were only two nursing assistants for the entire…
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 · F2024-05-16 · tag F0731 — widespreadRequest a waiver if it can't meet the nurse staffing requirements.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide licensed nursing staff on a 24 hour basis for 8 days in the first quarter of fiscal year 2024. Findings include: The facility's certification and survey provider enhanced report (CASPER) identified 20 days between October 1st 2023 and December 31st 2023 when there was no licensed nursing staff in the facility. During interview on 5/17/24 at 10:52 a.m., director of nursing (DON) stated the facility was staffed well now and the gaps in the CASPER were a result of their payroll software not working correctly. The facility's payroll records confirmed the following days included gaps of 6 hours or more with no licensed nursing staff: -10/7/23, gap in coverage on night shift -10/15/23, gap in coverage on night shift -10/22/23, gap in coverage on night shift -11/5/23, gap in coverage on night shift -11/11/23, gap in coverage on night shift -11/18/23, gap in coverage on night shift -11/19/23, gap in coverage on night shift -12/17/23, gap in coverage on night shift Information on payroll software problem was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-16 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform an elopement risk assessment for 1 of 1 (R1) resident reviewed for elopement. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and included diagnoses of Alzheimer's disease, dementia without behavioral or psychotic disturbance, major depressive disorder, recurrent, severe with psychotic symptoms. R1's provider orders dated 4/12/24, identified an order for staff to check placement and function of a wanderguard located on R1's right ankle, using a hand-held device to check the battery function each shift and to ensure R1 had not removed the device. R1's care plan dated 8/21/23, identified a risk for wandering with interventions to have a wander guard in place to right ankle, move closer to nurse's station for supervision due to wandering, encourage to attend activities during highest wandering times. R1's medical record did not contain an assessment for elopement risk. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement occupational therapy (OT) orders for proper wheelchair positioning for 1 or 2 residents (R31) reviewed for positioning. Findings include: R31's quarterly minimum data set (MDS) dated [DATE], identified R31's diagnoses include Dementia, generalized muscle weakness, and hemiplegia (paralysis of one side of body). R31 was severely cognitively impaired, used a wheelchair, and required substantial/maximum assistance with dressing, grooming, and transferring. R31's care plan dated 6/23/22, identified to keep side supports in wheelchair when resident up in wheelchair to prevent leaning to the left. Therapy progress note dated 3/6/24, states evaluation for wheelchair positioning completed. Resident was provided with lateral side wedges to further prevent leaning to left side. Please keep side supports in wheelchair when resident up in chair. During observation's on 5/14/24 from 1:03 p.m. to 6:31 p.m., R31 was observed hunched forward…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 maintain safe positioning for a resident with a feeding tube, while the tube feeding was running for 1 of 1 resident (R37) reviewed for tube feeding care. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of Parkinson's disease with dyskinesia (uncontrollable, uncoordinated movements), respiratory failure, pneumonitis due to inhalation of food and vomit, and dysphagia (a swallowing disorder). R37 was dependent on staff for oral hygiene, needed maximum assistance for bed mobility, and had a feeding tube. R37's provider orders dated 2/9/24, identified a nothing by mouth order, to provide medications via feeding tube only, and to keep head of bed (HOB) at 45 to 60 degrees for all feedings and flushes. Feeding times were 3 a.m., 9 a.m., 3 p.m., and 9 p.m. at 85 milliliters (mL) per hour. R37's care plan dated 4/27/23, identified R37 received nutrition through a feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 1 residents (R17) reviewed for respiratory care. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of heart failure, anxiety, type 2 diabetes, and a thyroid disorder. R17's physician orders dated 12/20/23, identified staff should change oxygen tubing weekly on Monday night shift. During observation on 5/14/24 at 12:22 p.m., oxygen tubing did not have a date. During observation on 5/17/24 at 9:12 a.m., oxygen tubing did not have a date. R17's treatment record indicated oxygen tubing was not changed in April or in May. During interview on 5/17/24 at 10:10 a.m., certified nursing assistant (CNA)-A stated nurses are responsible for changing oxygen tubing per orders. CNA-A confirmed there was no date on the oxygen tubing. During interview on 5/17/24 at 10:40 a.m., licensed practical nurse (LPN)-A stated nurses are responsible 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.
- Potential for harm · D2023-03-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to complete all sections on the Minimum Data Set (MDS) for 2 of 15 residents (R40, R38) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Resident Facility Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, OBRA-required comprehensive assessments include the completion of both the MDS and the CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. Section O: identified special treatment, procedures, and programs. The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. Section E: behavior. The items in this section identify behavioral symptoms in the last seven days that may cause distress to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-09 · 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, interview, and document review, the facility failed to complete morning cares for 1 of 3 residents (R26) reviewed for personal cares. Findings include: R26's health conditions dated 3/9/23, indicated R26's diagnoses included low back pain, major depressive disorder, and weakness. R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was severely cognitively impaired and required extensive assistance with personal hygiene, dressing, and toilet use. R26's care plan dated 6/24/22, indicated R26 required extensive assistance with grooming and personal hygiene. Staff were directed to encourage R26 to start grooming tasks and to assist with completion if he was unable. On 3/8/23, at 7:18 a.m. until 7:47 a.m. R26 was continuously observed. R26 was observed lying in bed with his eyes open, wearing oxygen running at two liters per minute. His feet were bare and were sticking out from under his covers. He was wearing a regular shirt. He was able to push his soft touch call…
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 · D2023-03-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure proper sanitary storage of resident medications within the medication cart and that expired medications were removed from surplus stock supply. In addition, the facility failed to ensure only authorized personnel had access to keys to get at drugs and biologicals stored in the medication room and the medication cart. Findings Include: On 3/8/23, at 10:59 a.m. licensed practical nurse (LPN)-A locked the medication cart located in front of the nurse's station, placed medication keys on cart surface and walked over to fridge to get milk while the keys remained on the cart. At 11:00 a.m. LPN-A proceeded into resident room with milk to administer pills. At 11:02 a.m. LPN-A returned to the medication cart and sanitized hands. On 3/8/23, at 11:14 a.m. the medication cart was parked across from the nurse's station. The medication cart keys were hanging on the cart computer arm. LPN-A was not in sight. Continuous observation of cart initiated. On 3/8/23, at 11:19 a.m. unknown staff used a different set 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.
“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 ST. FRANCIS HEALTH SERVICES — 14 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 | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 4.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 13 homes this chain runs (chain average 2.8★, 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 | Since |
|---|---|---|---|
| BACH, CURTIS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2024 |
| DRIPPS, DANIEL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| EHLERS, DOUGLAS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| GOODNOUGH, JENNIFER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| GRAMM, TIMOTHY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| LAIR, MICHAEL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LIENEMANN, STEVEN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LUETMER, JOHN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| NELSON, PATRICK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| PETERSON-DEVRIES, CAMI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2022 |
| RAW, CAROL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/16/2005 |
| RENTZ, LAURA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| RENTZ, PAUL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| SCHNEIDER, TODD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2013 |
| WIESE, LORRAINE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/25/2017 |
| BIG STONE THERAPIES, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/03/2015 |
| EIDE BAILLY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2023 |
| ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/10/2002 |
| ANDERSON, EMILY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/02/2017 |
| BAY, ESA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/07/2025 |
| BLEVINS, ROSANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/18/2018 |
| BURROWS, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2024 |
| CASPERS, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/29/2014 |
| COPEMAN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HANNEKEN, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/20/2022 |
| HEJHAL, ROXANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2023 |
| HOFMANN, REED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2023 |
| INCONTRO, ELISABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/17/2013 |
| JUST, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| MARLOW, JINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/06/2022 |
| MCGRAW, CINDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/15/1988 |
| RENTZ, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/22/2024 |
| ROCHE, SHANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2017 |
| RYAN, BEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/27/2012 |
| RYAN, GEOFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/12/1998 |
| STOCK, KELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2022 |
| THOMPSON, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/10/2018 |
| TOMOSON, APRIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/12/2021 |
| TOWNLEY, GLENDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/08/1999 |
| WALKER, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2024 |
| BARNARD, SHELLEY | Individual | ADP OF THE SNF | since 03/31/2025 |
| RAUSCH, AMY | Individual | ADP OF THE SNF | since 04/22/2025 |
CMS files one row per role, so the 100 rows in the source record cover these 42 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.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $278K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245245. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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.