Heartwood
503 Heartwood Drive, Crosby, MN 56441 · Non profit - Corporation · 54 certified beds · (218) 545-8500 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- 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
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 18.0% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.3% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.1% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 5.3% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 8.0% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 38.8% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 12.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.0% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.2% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 26.0% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 27.2% | 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.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 54 beds and averages 49.4 residents a day — about 91% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.451 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.77 hrs/resident/day on weekends vs 4.52 on weekdays — 17% thinner on weekends. RN hours go from 1.66 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
- Potential for harm · D2025-07-23 · 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 observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 1 of 5 resident (R6) reviewed for unnecessary medications.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of type 2 diabetes. R12 received an injection of insulin one day per week.R6's Order Summary Report dated 6/30/25, identified semaglutide (a GLP-1 receptor agonist used primarily for managing type 2 diabetes and aiding in weight loss, with significant effects on appetite regulation and blood sugar control.) subcutaneous solution pen-injector 2 milligram (MG)/3 milliliter (ML) inject 0.5 mg subcutaneously one time a day every Monday for type 2 diabetes.An email from the coding department director dated 7/23/25 at 1216: p.m., identified R6's semaglutide was coded as insulin in error.During an interview on 7/23/25 at 12:37 a.m., the director of nursing (DON) stated MDS…
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 · D2025-07-23 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 comprehensively assess for trauma informed care and identify potential triggers, to avoid potential re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of post traumatic stress disorder (PTSD).R6's medical record failed to identify a Trauma-Informed Care Assessment was completed.R6's care plan revised 5/9/25, did not include R6's PTSD triggers and/or interventions specific to his PTSD.During an interview on 7/21/25 at 2:22 p.m., R6 was lying in bed in her room. R6 spoke with a flat affect and stated she liked to keep to herself in her room. R6 stated she was unaware of any traumatic events in her life and could not recall anything that would make her upset specifically. During an interview on 7/23/25 at 9:05 a.m., registered nurse (RN)-B and nursing assistant (NA)-C stated they were both unaware of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 a unit refrigerator maintained a safe temperature for storage of food. This had the potential to affect all residents who received food from unit refrigerator. Findings include: During observation on 8/7/24 at 11:06 a.m., the unit refrigerator contained milk, cheese, and yogurt. A regular thermometer was not in the unit refrigerator and a request was made to the culinary director log of temperatures for the month of August 2024. During an interview on 8/7/24 at 2:12 p.m., the culinary director stated she did not know the range the unit refrigerator should be set at. When the unit refrigerator temperature was out of the set range of the automated monitoring system, an alert would be sent out to the culinary director, bio-med technician, and the executive director. The culinary director could not identify the temperature range or what temp she would be notified at. The History Detail Report for Skyview unit refrigerator dated 8/7/24, identified from 8/1/24 at 12:00 a.m. through 8/7/24 at 2:30 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-07 · tag 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 perform ongoing monitoring and wound care, as ordered, for a chronic reoccurring wound for 1 of 2 residents (R34) reviewed for wound care. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], identified R34 had diagnoses that included peripheral vascular disease (PVD) (a slow and progressive disorder of the blood vessels. PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected), high blood pressure, and coronary artery disease. R34 had one unhealed venous or arterial ulcer (a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing). R34's care plan revised 7/3/24, identified R34 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.
- Potential for harm · D2024-08-07 · 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 implement enhanced barrier precautions (EBP) for 1 of 2 residents (R34) reviewed for chronic wounds. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], identified R34 had diagnoses that included peripheral vascular disease (PVD) (a slow and progressive disorder of the blood vessels. PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected), hypertension, and coronary artery disease. R34 had one unhealed venous or arterial ulcer (a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing). R34's care plan revised 7/3/24, identified R34 had a potential alteration in skin integrity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide and document the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R20, R39, R42) reviewed for immunizations. Findings include: R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 was [AGE] years old and had diagnoses that included diabetes mellitus, and hypertension. R20's immunization record dated 8/7/24, identified R20 refused a pneumococcal conjugate (PCV20) vaccination. R20's admission note dated 6/20/24 at 12:48 p.m., identified R20 declined when offered pneumonia vaccine. However, the admission note failed to identify what education, if any, education R20 received regarding pneumococcal vaccination. R20's Care Center Pneumococcal Immunization Consent dated 6/20/24, identified R20's signed refusal of a pneumococcal vaccination. However, the document failed to identify which pneumococcal vaccine R20 was offered…
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 · Ecited before2023-07-19 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 5 of 5 residents (R11, R28, R36, R37, R42) reviewed for immunizations. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of congestive heart failure. R11's immunization record dated 7/19/23, identified R11 received the pneumococcal 23 (PPSV23) on 10/23/14 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/04/16. R11's medical record failed to provide evidence the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R11/R11's representative. R28's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of anemia (low blood count) and hypertension (high blood pressure). R28's immunization record from 7/19/23, identified R28 received PPSV23 on 2/4/15, and the PCV13 on 11/11/14. R28's medical record failed 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.3 | +0.7 vs chain |
| Health inspection | 4 of 5 | 3.4 | +0.6 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 20 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CROSBY SENIOR SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/02/2025 |
| CUYUNA REGIONAL MEDICAL CENTER | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/02/2025 |
| PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/02/2025 |
| U.S. BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 05/17/2023 |
| BERG, KATIE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| BLANK, KIMBERLY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| GOODWIN, DAVID | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/08/2025 |
| HART, AMY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| LARSON, DUANE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/02/2025 |
| LINDH, DANIEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| MEYER, MARK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2025 |
| PHS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/07/2025 |
| GRAMS, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/08/2025 |
| CUYUNA RANGE HOSPITAL DISTRICT | Organization | ADP OF THE SNF | — | since 01/22/2025 |
| BURGSTALER, LORI | Individual | ADP OF THE SNF | — | since 01/08/2025 |
| HALL, MICHAEL | Individual | ADP OF THE SNF | — | since 01/02/2025 |
| HOLMGREN, PAIGE | Individual | ADP OF THE SNF | — | since 01/02/2025 |
| HOROWITZ, JOSHUA | Individual | ADP OF THE SNF | — | since 01/02/2025 |
| KAUPHUSMAN, DAVID | Individual | ADP OF THE SNF | — | since 01/02/2025 |
| PEDERSON, MARK | Individual | ADP OF THE SNF | — | since 01/08/2025 |
| ROGERS, GRETCHEN | Individual | ADP OF THE SNF | — | since 01/14/2025 |
| SKJEVELAND, JAMIE | Individual | ADP OF THE SNF | — | since 01/02/2025 |
| TAYLOR, BART | Individual | ADP OF THE SNF | — | since 01/14/2025 |
| TWIGG, ROGER | Individual | ADP OF THE SNF | — | since 01/02/2025 |
CMS files one row per role, so the 48 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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.
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 245232. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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