Woodlake Healthcare And Rehabilitation Center
8000 Bass Lake Road, Crystal, MN 55428 · For profit - Individual · 188 certified beds · (763) 531-5000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.2% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.0% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.3% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.9% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.1% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 73.4% | 96.1% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.0% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.0% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.3% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.9% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 64.1% | 82.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.3% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.2% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.89 | 1.90 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 378 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.2% 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 125 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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 | 62.2%CMS range 57.1–66.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 8.4–13.3 | 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 | 51.2% | 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 | 39.2% | 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 | 45.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 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 | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.8–8.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 188 beds and averages 168.5 residents a day — about 90% occupied, or roughly 20 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 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.99 hrs/resident/day on weekends vs 4.39 on weekdays — 9% thinner on weekends. RN hours go from 0.98 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2025-12-18 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 4 residents (R17) reviewed for hospitalizations. Findings include:R17's admission Minimum Data Set (MDS) dated [DATE], indicated R17 was cognitively intact. R17 MDS indicated diagnosis of cancer, heart failure, renal insufficiency, and diabetes mellitus. R17's medical record identified the following MDS assessments:1) 7/8/25 discharge with return anticipated, with 7/17/25 entry record2) 8/1/25 discharge with return anticipated, with 8/4/25 entry record3) 8/17/25 discharge with return anticipated, with 8/25/25 entry record4) 9/29/25 discharge with return anticipated, with 10/5/25 entry record5) 10/23/25 discharge with return anticipated, with 10/29/25 entry recordA review of the facility information sent to the Ombudsman dated July 2025 through November 2025, lacked evidence of R17's name being included on the list of hospitalized residents. An interview on 12/18/25 at 11:24 a.m., director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-18 · 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 ensure timely follow up for recommendations from in-house provider for 1 of 1 (R161) resident reviewed for eye drops.Findings include: R161's quarterly minimum data set (MDS) dated [DATE], included R161 was cognitively intact. R161 had diagnoses of arthritis, anxiety and depression. During interview on 12/15/25 at 4:53 p.m., R161 stated she had an eye doctor appointment about a week ago had not received the eye drops that had been ordered. R161's HealthDrive Eye Care Group after visit summary (AVS) dated 12/2/25, included R161 reported itchy eyes. Under the AVS section plan, the following was listed:- Discontinue Medication Order(s) effective 12/02/2025: Artificial tears ophthalmic Solution (eye drops to treat dry eyes)- New Medication Order: olopatadine (eye drop for dry, itchy eyes) 0.2%, apply 1 drop, Both eyes, every morning for 90 days R161's order summary sheet dated 12/18/25, included artificial Tears Ophthalmic Solution 1.4 % (Polyvinyl…
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 before2025-12-18 · 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, and interview the facility failed to ensure all medications and biologicals were locked in compartments which only allowed authorized personnel to have access. This had the potential to affect all residents, staff, and visitors.Findings include:During constant observation on 12/16/25 from 1:27 p.m. through 1:40 p.m., an insulin pen was observed laying on top of a locked treatment cart. The treatment cart was passed by a resident and multiple staff; none noted the insulin pen or interacted with it.On 12/16/25 at 1:40 p.m., the licensed practical nurse (LPN)-B was stopped at the cart and stated they had no idea where the pen was from or how it got there. LPN-B stated they were expected to keep the insulin pens in the medications cart, went to their cart, and pulled out a currently opened pen for the same resident. LPN-B then stated they would report the incident to their nursing supervisor and remove the pen from circulation.On 12/16/25 at 1:55 p.m., the registered nurse manager (RN)-A stated they had recently changed their processes, and the staff nurses were…
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 · E2025-09-12 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to maintain an environment that was clean and free from odors for 3 of 3 residents (R1, R2, R3) reviewed for environmental concerns. Findings include:During observation of the two-east unit on 9/11/25 at 10:50 a.m., a musty odor was observed outside room [ROOM NUMBER]. During observation on the east unit on 9/12/25 at 8:23 a.m., the hallway outside of room [ROOM NUMBER] smelled of urine. No trash or linen carts were in the vicinity.R1's admission Record indicated he admitted to the facility on [DATE]. Diagnosis included Surgery of digestive system, chronic pain, and weakness. During interview on 9/11/25 at 10:39 a.m., family member (FM)-A stated it smelled like death in his dad bathroom when he was at the facility even after they had cleaned it. R2's admission Record indicated she admitted to the facility 9/3/25 and resided on the two- east unit of the facility. Diagnosis included muscle weakness, DMII, hypertension and history of falls.…
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 · D2025-09-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure reasonable accommodation of resident needs and preferences upon admission to the facility for 2 of 3 residents (R1, R3) reviewed who reported concerns related to accommodation of needs upon admission to the facility.Findings include: R3's admission Record indicated admitted to the facility on [DATE] at 12:45 p.m. Diagnosis included fractures of left fibula and tibia (the two bones of the lower leg), pain in left wrist and left leg, fracture of left radius (one of two bones in your forearm), unsteadiness and dependence on other enabling machines and devices.R3's Interagency Transfer Orders dated 9/4/25, included oxyCodone 5 milligrams (mg). Give 5-10 mg every four hours as needed for pain. The orders indicated R3 had restricted weight bearing and indicated non-weight bearing on left leg and left arm, okayed for a platform walker at the left elbow.R3's Medication Administration Record (MAR) dated 9/1/25 through 9/30/25, indicated the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · 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 interview and document review, the facility failed to ensure assistance, to resident triggered call light needs, was provided timely to promote dignity and reduce the risk of potential complications (i.e., incontinence, skin impairments, falls, changes in condition, etc.) for 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, R8) who expressed concerns related to extended call light response times and associated potential risk factors to their health.R8:R8's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 lacked communication impairments and required some form of physical assist with most of his ADLs and mobility. R8 was frequently incontinent of bowel and bladder, at risk for pressure ulcers, and was diagnosed with diabetes, Parkinson's disease, and muscle weakness. R8's medical record identified his most recent brief interview for mental status (BIMS) was 15 (cognitively intact). R8's admission Record, printed [DATE], identified he desired CPR if his heart were to stop beating. R8's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately, but no later than two hours, report to the state agency an allegation of abuse for one of three residents (R1) reviewed for employee to resident sexual abuse. Findings include: During an observation on 11/26/24 at 10:15 a.m. R1 was in his room calling out to nurse manager (NM)-A who was walking past R1's room. R1 was heard saying they said not to take the abuse allegations lightly, so I called 911 again and they told me to call the sergeant. NM-A asked R1 if the police officer came to talk to him and R1 stated no. R1 stated he wanted that woman arrested for abuse. NM-A stated, it was not abuse. R1 stated it was sexual abuse. NM-A stated to R1 it was not sexual abuse and walked out of R1's room. R1's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of gas gangrene. R1's additional diagnoses included pathological fracture on right radius, malignant neoplasm of prostate, paranoid…
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 before2024-10-25 · 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 record review the facility failed to provide and maintain dignity for 1 of 1 residents (R106) reviewed for dignity. Findings Include: R106's quarterly minimum data set (MDS) dated [DATE], indicated a severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming and toileting. R106's care plan dated 7/21/24, indicated R106 required extensive assist of 1 staff for dressing and grooming. The care plan did not indicate if R106 preferred to wear her own clothes or a hospital type gown. On 10/22/24 at 3:26 p.m., R106 was in her room, sitting in her wheelchair wearing a white with blue flowers hospital type gown. R106 did not have on any type of footwear. R106's hair was uncombed and had areas that appeared to be matted and other areas that stood up approximately 2 inches from her scalp. During observation and interview on 10/22/24 at 3:31 p.m. certified nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-25 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R423) reviewed. Findings include: R423's annual Minimum Data Set (MDS) dated [DATE], identified R423's cognition as moderately impaired and needed assistance with of one staff with activities of daily living (ADL's). During an observation on 10/24/24 at 7:45 a.m., R423 was laying in her bed with lights on. R423 had a tube of Asper Crème (treats muscle and joint pain), a container of petroleum jelly, and two bottles of Nystatin powder in the yellow bin next to the nightstand and unsecured. R423 stated the nursing assistant (NA) put that on for me. During medical record review on 10/24/24, the medical record lacked evidence of an assessment for self-administering medications (SAM) being completed. The medical record lacked evidence of a physician order for a SAM. During an interview on 10/24/24 at 9:33 a.m., NA-A stated R423 requested…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-25 · 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 record review, the facility failed to ensure assistance with dressing and grooming for 1 of 3 residents (R106) reviewed for activities of daily living (ADL) care provided for dependent residents. Finding include: R106's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming, bathing, oral cares and toileting. The MDS indicated R106 did not reject or refuse cares. R106's care plan dated 7/21/24, indicated R106 had an ADL deficit related to dementia and required extensive assist of 1 staff for dressing, grooming, bathing, and elimination. The care plan indicated R106 would receive the necessary assistance with all ADL's. The care plan also indicated R106 did not have any natural teeth and instructed staff to assist with denture placement every AM and removal every PM. The care plan instructed staff 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.
Show the remaining 15 citations
- Potential for harm · D2024-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure care plan interventions were being utilized for 1 of 2 residents (R106) reviewed for safety. Findings include: R106's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming and toileting. R106's care plan revised on 9/15/24, indicated R106 was at risk for falls and had a history of falls. Interventions included staff assistance by placing the call light where the resident can reach it before exiting the room each time, and ensure all personal belongings are within reach for the resident. During continuous observation on 10/25/24 beginning at 10:11 a.m. through 11:06 a.m., R106 was lying in her bed. A white call light with a red button to push for assistance was noted to be lying on the floor under the bedside table approximately 2 feet away, outside of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to notify the physician of change in condition for 1 of 3 (R1) reviewed for change of condition. Findings include R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 required set up assist for eating and oral care. R1 required substantial/maximal assist of one person to transfer chair to bed. R1's care plan dated [DATE], identified R1 was at a safety risk and may fall due to history of stroke with right sided weakness. R1 had a diagnosis of thrombocytopenia, hypertension, chronic heart failure, and dementia. Staff were to check on R1 regularly to try to anticipate R1's needs. Keep call light and commonly used items within reach. R1's nurse practitioner (NP) note dated [DATE], identified R1 was seen by NP due to testing positive for COVID-19 during routine testing on this day. R1 reported…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-12 · 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 document review the facility failed to follow the person-centered care plan for 1 of 1 residents (R1) reviewed for activities of daily living (ADL). Findings included: R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 required set up assist for eating and oral care. Personal hygiene is not completed. R1 required substantial/maximal assist of one person to transfer chair to bed. R1's care plan dated 6/24/22, identified R1 is at a safety risk and may fall due to history of stroke with right sided weakness. The care plan directed staff to check on R1 regularly to try to anticipate R1's needs. Keep call light and commonly used items within reach. R1's bowel and bladder care plan dated 6/26/22 directed staff to offer the bathroom when waking up, after breakfast, before and after lunch, before and after supper,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-12 · 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 comprehensively assess and monitor after an acute change of condition related to increased weakness/fatigue was identified was identified for 1 of 3 residents (R1) reviewed for change of condition Findings include R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's provider orders for life-sustaining treatment (POLST) dated 6/16/22, identified cardiopulmonary resuscitation (CPR) should be attempted. Medical treatments indicated full treatment. Transfer to hospital and/or intensive care unit if indicated. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 was independent with eating and oral care. R1 required partial to moderate assistance with personal hygiene. R1's cognition was not identified. R1's care plan dated 1/26/24 identified R1 was at risk for exposure of Covid infection due to residing in congregate living facility, co-morbid conditions, advanced age and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-26 · 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 record review, the facility failed to ensure food temperatures were taken in the kitchenettes to prevent foodborne illness. This had the potential to affect all 161 residents currently residing in the facility. Finding include: During an observation of temperature taking of the lunch meal on 1/26/24 at 10:30 a.m., with dining manager (DM) and the campus dining service and purchasing director (CDSPD) the cook documented the temperature of the meat on a Quality Checklist Sheet (QCS) dated 1/26/24. When asked to see the last month of temperature logs the DM produced completed lunch and dinner temperature logs. At 10:50 a.m. the DM stated she did not have any breakfast QCS logs. On 1/26/24 at 11:05 a.m. CDSPD produced three QCS logs dated 1/19/24, 1/23/24, and 1/25/24 that had temperatures for the breakfast meal. During an interview on 1/26/24 at 11:35 a.m., dining service aid (DSA)-A stated she had served the breakfast that morning and did not have time to take the temperatures. DSA-A stated the temperatures of all food should be taken before…
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 · E2024-01-26 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a written notification of transfer was provided for 3 of 6 residents (R119, R126, R128) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 5 of 6 residents (R119, R128, R45, R50, R59), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital. Findings include: R119's quarterly MDS dated [DATE], indicated R119's diagnoses included dementia with severe cognitive impairment. Progress notes indicated R119 was hospitalized from [DATE] through 10/24/23. R119's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R119's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R126's admission MDS dated [DATE], indicated R126's diagnoses included acute respiratory failure, and R126 was cognitively…
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 before2024-01-26 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 document review the facility failed to ensure 3 of 6 medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect all residents that resided on the first and second floors in the facility. Findings include: On 1/24/24 from 11:02 a.m. to 11:31 a.m., 1st floor medication cart (A) was unlocked and unattended. There were also approximately five to six residents within 10 feet of the open medication cart. On 1/24/24 from 11:42 a.m. to 11:51 a.m., 2nd floor medication cart (B) was observed unlocked and unattended. No residents were in the vicinity of the open medication cart. On 1/25/24 from 2:14 p.m. to 2:16 p.m., 2nd floor medication cart (C) was observed unlocked and unattended. No residents were in the vicinity of the open medication cart. On 1/24/24 at 9:31 a.m., registered nurse manager (RN)-B stated she expected all medication and treatment carts to be locked when unattended. On 1/24/24 at 4:00 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 · E2024-01-26 · tag F0880 — failed to prevent and control infections — patternProvide 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 ongoing infection prevention and control program to prevent the spread of infection due to lack of appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R6) on transmission-based precautions (TBP) for COVID-19. In addition, the facility failed to disinfect a multi-use mechanical lift used by COVID positive resident. This affected 2 of 2 residents (R2, R95), and had the potential to affect all 166 residents in the facility. Findings include: R6's quarterly MDS dated [DATE], indicated R6 had moderate cognitive impairment, traumatic brain injury, and bipolar disorder. R6's progress noted dated 1/22/24 at 1:57 p.m., indicated positive for COVID-19. R6 was placed on transmission-based droplet precautions, and would remain on isolation precautions until 1/27/24. R95's annual Minimum Data Set (MDS) dated [DATE], indicated short-term and long-term memory problems, and diagnoses included dementia, adult failure 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 · Dcited before2024-01-26 · 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 observation, interview, and document review, the facility failed to assess the resident and determine safety for 1 of 1 resident (R103) reviewed for self-administration of medications (SAM) . Findings include: R103's quarterly Minimum Data Set (MDS) dated [DATE], indicated R103 had moderate cognitive impairment. R103's Self Administration of Medication assessment dated [DATE], indicated assessment for the self-administration of nebulizer treatment, no other medications were included in the assessment. R103's order summary report dated 1/4/2024, indicated SAM orders for Ipratropium-Albuterol nebulizer, Ketotifen Fumarate eye drop, Loratadine, Synthroid, and Trolamine cream. However, no SAM orders for Colace, iron, metoprolol, and Prilosec. R103's care plan dated 1/25/24, identified SAM orders for some medications. However, Colace, iron, metoprolol, and Prilosec were not included. During observation on 1/24/24 at 4:00 p.m., the licensed practical nurse (LPN)-B prepared medications for R103 including;…
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 · D2024-01-26 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 a written notice of a bed hold upon transfer for hospitalization for 1 of 5 residents (R119) reviewed for hospitalization. Findings include: R119's quarterly Minimum Data Set (MDS) dated [DATE], indicated R119's diagnoses included dementia and severe cognitive impairment. A progress note dated 10/20/23 at 10:23 p.m., indicated R119 was sent to the hospital at 6:00 p.m., and was admitted to the Veteran's Administration (VA) hospital for sepsis via urinary source. R119's progress notes had no evidence a bed hold notice was provided to the resident and/or responsible party. A subsequent progress note dated 10/24/23 at 11:14 a.m., indicated R119 returned from the VA hospital on [DATE] at 10:57 a.m. On 1/25/24 at 9:00 a.m., director of social services (DSS) stated a notice of voluntary transfer form and written notice of bed hold should have been filled out with the resident, and the social worker should have acted as a backup to follow up on 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 · D2024-01-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a urinary catheter drainage bag was kept below the level of the bladder to prevent infection for 1 of 1 residents (R121) reviewed for catheter care. Findings include: R121's face sheet indicated diagnoses included malignant neoplasm (cancer) of prostate, secondary malignant neoplasm of bone, and metabolic encephalopathy (brain dysfunction due to chemical imbalance). R121's quarterly Minimum Data Set (MDS) dated [DATE], indicated was severely impaired cognition. R121's care plan initiated 7/12/23, indicated at risk for developing a urinary tract infection (UTI) due to catheter use, and staff would provide catheter cares to keep free from catheter related complications. On 1/22/24 at 1:40 p.m., R121 was observed seated in his wheelchair in his room, facing the hallway, approximately three feet from the entryway. R121's catheter tubing extended upwards from the bottom of R121's right pant leg, arched approximately three inches above…
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 · D2024-01-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 2 of 5 residents (R121, R147) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R121's immunization report, dated 1/26/2024, indicated R121 was [AGE] years old, received PPSV23 on 5/24/2004 and PCV13 on 9/24/2014. The record…
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 before2024-01-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report to the State Agency (SA) immediately for an injury of unknown origin for 1 of 1 residents (R1) who was discovered to have a suspicious bruise (labia area). Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had moderate cognitive impairment. R1's diagnoses included anemia, peripheral vascular disease, depression, and diabetes. During interview on 1/19/24 at 11:01 a.m., director of nursing (DON) stated R1 was taken to the emergency room due to overall decline and increased confusion and upon review of hospital records it was noted a bruise was found on R1 labia. DON stated no report to the SA was completed due to the hospital contacting the SA. DON confirmed an investigation was completed. Review of facility's internal investigation lacked evidence a report was submitted to SA. The facility's policy titled Abuse, Neglect and Exploitation dated 10/2022 indicated reporting of all alleged violations to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and document review, the facility failed to notify a resident consulting urologist and medical provider group for 1 of 3 residents (R1) when he missed eight antibiotic doses while being treated for a urinary tract infection (UTI). R1's Minimum Data Set (MDS) dated [DATE], indicated he had moderate cognitive impairment, heart, and end stage kidney disease. He did not exhibit any behaviors, nor refuse care from staff, and needed extensive assistance from one nursing staff to get on and off the toilet. R1's care plan dated 11/3/23, indicated he needed extensive assistance from one nursing staff every two to three hours to get on and off the toilet. The care plan did not identify a risk for developing a UTI, bladder scan requirements, and when to drain his bladder with at catheter. R1's urology visit note dated 11/30/23, indicated R1 had only one kidney, and experienced an inability to completely empty his bladder when he urinated. During the visit R1 had over 800 cc (cubic…
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 before2023-12-28 · 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 observations, interview and document review the facility failed to develop a comprehensive care plan for 1 of 3 residents R1 when his care plan did not identify risks, goals, and interventions to address his chronic kidney failure, chronic kidney infection, urinary retention, post void residual bladder scan (a scanning device to show how much urine was left in the bladder after he urinated), and intermittent catheterization (a catheter inserted into the bladder to drain a buildup of urine.) R1's Minimum Data Set (MDS) dated [DATE], indicated he had moderate cognitive impairment, heart, and end stage kidney disease. He did not exhibit any behaviors, nor refuse care from staff, and needed extensive assistance from one nursing staff to get on and off the toilet. R1's November and December medical administration record (MAR) dated 11/30/23 through 12/10/23, indicated R1 received Keflex to treat a UTI. R1's urology visit note dated 11/30/23, indicated R1 had only one kidney, and experienced an inability 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.
Who owns this facility
CMS ownership filings flag an owner of this facility as a private-equity firm. That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.
- THE ALLIVEN GROUP LLC — private equity · 4.20% share · 5% Or Greater Indirect Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEW HOPE OPERATOR HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/08/2025 |
| CCP MN HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| MN HC PARTNERSHIP 102 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| MN HOLDINGS 102 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| NEW HOPE HC LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| RSYT 2024 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| RYST 2024 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| THE ALLIVEN GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| TSI FAMILY TRUST 2024 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/08/2025 |
| KNOBEL, REUVEN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| TARLOW, LEON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| POPULAR BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 08/01/2024 |
| BRADY, JAIME | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| SCHMITZ, MICHAELA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/14/2024 |
| TAYLOR, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| MURPHY, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| RASQUINHA, CLEMENCIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| 8000 BASS LAKE ROAD LLC | Organization | ADP OF THE SNF | — | since 01/08/2025 |
| CENTRALIZED BUSINESS SERVICES LLC | Organization | ADP OF THE SNF | — | since 08/01/2024 |
| CHNH CONSULTING LLC | Organization | ADP OF THE SNF | — | since 01/08/2025 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | — | since 08/01/2024 |
| DIGACORE CONSULTING | Organization | ADP OF THE SNF | — | since 01/08/2025 |
| LT CARE ACQUISITION CORP | Organization | ADP OF THE SNF | — | since 08/01/2024 |
| NEW HOPE REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/08/2025 |
| TURNING POINT CONSULTING LLC | Organization | ADP OF THE SNF | — | since 08/01/2024 |
| GOTTESMAN, DANIEL | Individual | ADP OF THE SNF | — | since 01/08/2025 |
CMS files one row per role, so the 48 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
18 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 $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245518. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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.