Essentia Health Homestead
115 10th Avenue Northeast, Deer River, MN 56636 · Non profit - Corporation · 32 certified beds · (218) 246-4336 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $67,727 in federal fines (most recent 2026-03-31)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.7% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.0% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.4% | 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 | 0.0% | 4.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 9.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.1% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.6% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.8% | 17.1% | 17.1% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show <0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 32 beds and averages 20.8 residents a day — about 65% occupied, or roughly 11 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.56 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.44 hrs/resident/day on weekends vs 5.19 on weekdays — 14% thinner on weekends. RN hours go from 1.94 to 1.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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.
15 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · K2025-12-17 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 an un-licensed nursing student (NS) was supervised during resident medication administration, including significant medication such as insulin, liquid morphine and other controlled substances. In addition, NS did not possess a nursing license, competencies, or skills set to provide necessary resident nursing services nor other certification required for medication administration. This had the likelihood for a serious adverse outcome and placed 4 of 4 residents (R2, R3, R6, R7) in immediate Jeopardy (IJ). The IJ began on 12/12/25, when the NS was observed administering insulin to a resident without direct supervision by a licensed nurse. The administrator was notified of the immediate jeopardy at 5:05 p.m. on 12/16/25. The immediate jeopardy was removed on 12/17/25, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate…
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.
- Actual harm · Gcited before2026-05-18 · 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 the care plan was followed for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm to R1 when she fell out of bed and sustained a femur (the longest, heaviest, and strongest bone in the human body, located in the upper leg) fracture. Findings include: R1's Resident Face Sheet indicated she was admitted to the facility 3/28/23. Diagnoses included Parkinson's disease, dementia, anxiety and repeated falls. R1's comprehensive Minimum data set (MDS) dated [DATE], identified severely impaired cognition. The MDS indicated R1 was dependent on staff for bed mobility and transfers. R1's John Hopkins Fall Risk Assessment Tool dated 4/30/26, indicated a low risk for falls. R1 care plan dated 5/12/26, identified a risk for falls related to diagnosis of Parkinson's disease, dementia, hallucinations, impaired mobility, weakness and decreased safety awareness. The care plan identified: Fall on 3/28/23. Interventions included:…
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.
- Actual harm · Gcited before2026-03-31 · 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 planned interventions were implemented to reduce the risk for falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm to R1 who fell from her wheelchair and sustained a fracture, head injury and lacerations to her hand. Findings include:R1's Continuity of Care Document created 4/1/26, indicated she admitted to the facility 1/5/22. R1's diagnosis included aphasia (communication disorder- may affect written and spoken language as well as ability to understand), dysphagia (difficulty swallowing) muscle weakness and dependence on enabling machines and devices for transfers.R1's John Hopkins Fall Risk Assessment Tool dated 1/5/26, indicated a high risk for falls.R1's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated she required substantial/maximal assistance for transfers. The MDS indicated R1 was dependent on staff for transport in a manual wheelchair.R1's care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-22 · 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 to disinfect a point of care glucose monitor between the use for 2 of 2 residents (R5, R18) who were observed to have their blood glucose checked. Findings include: R5's admission Minimum Data Set, dated [DATE], identified R5 had a diagnosis of diabetes mellitus (DM) and received insulin on a regular basis. R5's care plan dated 4/1/26, identified to monitor blood glucose (sugar) per orders. R5's orders dated 3/10/26, identified to have blood sugar checked three times a day. R18's quarterly MDS dated [DATE], identified R18 had a diagnosis of DM and received insulin on a regular basis. R18's care plan dated 3/5/26, identified to monitor blood sugar per order. R18's orders dated 4/15/26, identified R18 was to have blood sugar checked 4 times a day. During observation on 4/20/26 at 4:37 p.m., registered nurse (RN)-A used the point of care glucose monitor and obtained a blood sugar on R5. RN-A then placed the glucose monitor on R5's overbed table…
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 · D2025-12-17 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to implement a grievance process for 1 of 8 residents reviewed who expressed care concerns to the facility. Findings include: R1's annual Minimum Data Set, dated [DATE], identified intact cognition and diagnosis of fractures, heart disease and dependence on enabling machines. R1's care plan dated 12/18/25, identified an alteration in mobility related to fracture of lumbar spine, weakness and pain. The care plan directed staff to transfer R1 using a mechanical lift. An electronic (e)-mail from R1 to the director of nursing (DON) and administrator dated 11/12/25, indicated the following:R1 wrote, Asking for help with two issues. On 10/12/25, during transfer to the shower chair something went wrong and R1 ended up with a giant and very painful bruise on the inside of his leg. After the incident for approximately two plus weeks, it was too painful to transfer, so other than two times he did not get up for lunch and except for shower days he remained in bed.…
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 before2025-12-17 · 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 staff utilized the proper sling sizes when performing transfers via mechanical lift for 4 of 5 residents (R1, R2, R4, R5) who utilized a mechanical lift for transfers. Findings include: R1's annual Minimum Data Set, dated [DATE], identified intact cognition and diagnosis of fractures, heart disease, obesity and dependence on enabling machines. R1's care plan dated 12/18/25, identified an alteration in mobility related to fracture of lumbar spine, weakness and pain. The care plan directed staff to transfer R1 using a mechanical lift but lacked evidence of a sling size. R1's Essentia Lift and Move Profile dated 9/20/25 indicated the need for a full body lift, indicated he was not able to lift himself into a standing position and indicated he did not weigh less than 265 pounds (lb.) The assessment indicated sling size LL (purple), 220-350 lbs. R1's care plan dated 10/8/25, identified an alteration in physical mobility related 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 · D2025-07-30 · 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 allegations of drug diversion to the state agency (SA) and law enforcement within 24 hours for 4 of 4 residents (R1, R2, R3, R4) reviewed for drug diversion. This had the potential to affect all residents who were prescribed narcotics.Findings include:R1's quarterly Minimum Data Set, dated [DATE], identified R1 was cognitively intact and had diagnoses including quadriplegia and neurogenic bladder. R1 required assistance for activities of daily living (ADL's), had functional limitation in range of motion with bilateral upper and lower extremities and used a motorized wheelchair for locomotion. R1 had almost constant pain which occasionally affect sleep. R1's pain was rated #7 on a 0-10 scale (0=no pain, 10=worst pain) and received scheduled and as needed (PRN) opioid medications for pain.R1's physician orders report dated 6/30/25 through 7/30/25, identified orders for oxycodone 10 mg tablet give 1 tablet orally every 4 hours as needed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-03-12 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview the facility failed to ensure residents' mail and packages were delivered on Saturdays for 2 of 2 residents (R2, R8) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 20 residents residing in the facility. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was cognitively intact. R2's quarterly MDS dated [DATE], identified R2 was cognitively intact. During an interview on 3/11/25 at 1:10 p.m., at the resident meeting, R8 stated she did not receive mail or packages on Saturdays. R8 stated when packages were set to arrive late Friday or early Saturday, R8 would not receive them until Monday. R2 stated he did not receive mail or packages on Saturdays. R2 stated he received notifications when packages arrive at the facility on Saturday; however, would not receive the packages until Monday. R2 stated mail and packages come in through the main hospital and is sorted there and then delivered to the nursing home. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-03-12 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to accurately submit hours for the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 20 residents residing in the facility. Findings include: The facility's PB&J data for quarter four submitted to CMS for 7/1/24 through 9/30/24, identified the facility was triggered for excessively low weekend staffing, and failed to have licensed nursing coverage 24 hours/day for the following days: 31 out of 31 days during the month of July 2024, 31 out of 31 days during the month of August 2024, and 30 out of 30 days during the month of September 2024. In addition the report identified the facility triggered for no registered nurse (RN) coverage for eight consecutive hours for the following days: 31 out of 31 days during the month of July 2024, 8/1/24, 8/5/24, 8/9/24, 8/15/24, 8/19/24, 8/21/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 9/3/24, 9/4/24, 9/6/24, 9/7/24, 9/8/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, and 9/25/24, 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 before2025-03-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to identify a diagnosis for a medication for 1 of 5 residents (R4) reviewed for unnecessary medications. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses of dementia with behavioral disturbance, bi-polar disorder (a chronic mental health condition characterized by significant and persistent shifts in mood), and manic depression. The MDS identified R4 received an antidepressant. R4's order summary report dated 1/15/25, included an order for escitalopram (a medication used to treat depression) 10 milligram (mg) tablet, take 15 mg each morning. The medication order failed to include a diagnosis or indication for use. During an interview on 3/12/25 at 5:23 p.m., registered nurse (RN)-A stated each prescribed medication needed a diagnosis or reason for use. RN-A had entered R4's escitalopram order after a medication change and forgot to put the diagnosis in. During an interview on 3/12/25 at 5:25 p.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to ensure medications were properly labeled to prevent medication errors for 1 of 7 residents (R11) observed during medication pass. Findings include: R11's quarterly minimum data set (MDS) identified R11 had moderate cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R11's physician orders report dated 2/12/25 through 3/12/25, identified R11 was to receive anoro ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation - administer 1 puff into the lungs one time a day with a start date of 7/24/24. On 3/12/25 at 7:18 a.m., licensed practical nurse (LPN)-A was observed during a medication pass. LPN-A removed a foil container from a medication cart. Inside the container was an inhaler with R11's name and a label identifying the medication as anoro ellipta 62.5-25 mcg/act LPN-A stated the inhaler belonged to R11 although it did not have a label identifying how the medication should be administered. LPN-A stated most-likely the facility received the inhaler in a box labeled with the residents…
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 before2024-05-16 · 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
Based on observation, interview, and record review, the facility failed to ensure that residents dining in the main dining room were given an opportunity to sanitize their hands prior to meal consumption. This deficient practice had the potential to impact all resident who dined in the main dining room. Findings include: During a dinner meal observation on 5/13/24 that started at 5:36 p.m., there were residents seated at five tables in the main dining room waiting for their meals to be delivered. None of the tables had hand sanitizing products on them. During dining observation, there were no observations of staff offering hand sanitization to residents that entered the dining room or to those already seated in the dining room. During a breakfast meal observation on 5/15/24 that started at 7:00 a.m., several residents were seated at tables in the dining room. None of the tables had any hand sanitizing products on them tables. Staff were observed assisting residents with clothing protector application. Staff appropriately sanitized their own hands at the sink between residents and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medication use was limited to 14 days or notes from a provider face to face visit to demonstrate medical justification was provided to support ongoing use for 2 of 5 residents (R16, R20) reviewed for unnecessary medication use. Findings include: R16: R16's quarterly Minimum Data Set (MDS), dated [DATE], identified R16 had severe cognitive impairment, consumed antipsychotic medication daily and on an as needed (PRN) basis. R16's diagnoses included Alzheimer's and dementia. R16's most recent Physician Order Report, dated 5/16/24, identified R16's current physician-ordered medications. These included Haldol and Risperdal (both antipsychotic medication) on a PRN basis. The start date for Risperdal was 5/25/23 with no stop date documented. The start date for Haldol was 10/11/23 with no stop date documented. R16's medical record was reviewed and lacked evidence the provider had done every two weeks face to face visits…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-07-30 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to develop policies and procedures for when to report a suspected crime to law enforcement. This had the potential to affect all residents residing in the facility.Findings include:The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 11/24, identified local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility. the policy included reporting a suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated; however, lacked further examples of crimes that should be reported.During interview on 7/30/25 at 4:19 p.m., the director of nursing (DON) stated the facility abuse policy identified allegations of drug diversion should be reported to the state agency within 24 hours of suspicion and should be reported to MN Board of Nursing. The DON did not recall what the policy identified regarding what suspected crimes should be reported or when they should be reported to law enforcement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-12 · tag F0732 — widespreadPost nurse staffing information every day.
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 required nurse staffing information was consistently posted on a daily basis. This had potential to affect all 20 residents, staff, and visitors who may wish to view the information. Findings include: On 3/10/25 at 6:09 p.m., upon entering the unit, the facility nurse staff posting was hanging on a cork board on the wall across from the dining room. The staff posting was dated 3/9/25. The document listed staff scheduled hours per shift for each nursing job class. However, the posting was dated 3/9/25, one day prior. On 3/11/25 at 8:40 a.m., the cork board across from the dining room where the nurse staff posting was hanging the day prior was observed. The same section of the cork board was empty and the nurse staff posting was not hanging on the cork board. On 3/11/25 at 11:55 a.m., the director of nursing (DON) stated the night nurse was responsible for completing the daily staff posting for the following day. The most recent form was completed for 3/9/25, which was removed and another form for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$67,727 in federal fines across 2 penalties.
- $27,378 — penalty dated 2026-03-31
- $40,349 — penalty dated 2025-12-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ESSENTIA HEALTH — 6 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 | 2 of 5 | 4.3 | -2.3 vs chain |
| Health inspection | 1 of 5 | 3.5 | -2.5 vs chain |
| Staffing | 5 of 5 | 5.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 3.3 | +0.7 vs chain |
The other 5 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 |
|---|---|---|---|---|
| ESSENTIA HEALTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/01/2025 |
| ARONSON NORR, NANCY | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| BACHAND, ADAM | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| BERGSTROM, AMY | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| DUININCK, TROY | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| JAMAR, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| LOBAN, GEORGE | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| LUND, JARED | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2024 |
| SMITH, BRUCE | Individual | CORPORATE DIRECTOR | — | since 01/01/2026 |
| TERCH, JUSTIN | Individual | CORPORATE DIRECTOR | — | since 10/22/2025 |
| URBANSKI, REBECCA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| WATTERS, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| YUNG, ANTHONY | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| BOREN, KEVIN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/04/2022 |
| SERTICH, ANTHONY | Individual | CORPORATE OFFICER | — | since 01/01/2021 |
| SKORUPA, KRISTA | Individual | CORPORATE OFFICER | — | since 05/06/2024 |
| ST MARYS DULUTH CLINIC HEALTH SYSTEM | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/12/2025 |
| MEYER, DEBORAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/22/2019 |
CMS files one row per role, so the 23 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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 245428. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.