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Emmanuel Nursing Home

1415 Madison Avenue, Detroit Lakes, MN 56501 · Non profit - Corporation · 57 certified beds · (218) 847-4486 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Feb 20261 immediate-jeopardy citation$53,847 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $53,847 in federal fines (most recent 2026-01-28)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

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

Location & what’s nearby

Hospital
Urgent care / clinic
1112 Lincoln Ave · (218) 847-0883 · Call to confirm hours
Pharmacy
1245 Washington Ave., Suite B · (218) 846-2276 · Call to confirm hours
Grocery
310 Frazee St E · (218) 844-2002 · Call to confirm hours
Park
1355 Washington Ave · Typically dawn to dusk
Place of worship
1401 Madison Ave · (218) 847-7211

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

Quality measures — how residents actually fare

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

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.5%18.2%15.4%typical
Long-stay residents who lose too much weight6.8%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.6%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection8.2%2.6%2.0%worse
Long-stay residents with depressive symptoms0.7%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.4%4.0%3.3%better
Long-stay residents whose ability to walk worsened22.0%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.3%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers6.0%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control26.5%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table30.6%17.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.1%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine93.8%82.7%79.4%better
Short-stay residents rehospitalized after admission33.2%23.5%22.6%worse
Short-stay residents with an outpatient ER visit14.1%14.8%12.0%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

61.0% 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 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.0%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
67.4%U.S. median 56.6%
Met the expected recovery
0.64U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 67.4% 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 86 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 0.64 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.0%CMS range 51.8–67.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.6–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 2.8–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.52
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.38
Aide hours/ resident / day
4.57
Total nurse hours/ resident / day
0.82
RN hoursweekends
48.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 57 beds and averages 49.6 residents a day — about 87% occupied, or roughly 7 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 4.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.52 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 3.93 hrs/resident/day on weekends vs 4.82 on weekdays — 19% thinner on weekends. RN hours go from 1.80 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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

4
deficiencies at the latest standard inspection (2026-02-11)
3
at the previous standard inspection (2024-12-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-28 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 modified diet orders were served in accordance with physician's orders for 3 of 4 residents (R1, R2, R3) who were at risk of aspiration and choking. This resulted in an immediate jeopardy for R1 and R3 when R1 was served food despite a strict order for nothing by mouth (NPO) and R3 who had a history of dysphasia (difficulty swallowing) and was served non pureed meat, not in accordance with the prescribed diet. The IJ began on 1/19/26, when dining assistant (DA) served R1 a regular textured meal consisting of a sandwich against physician's orders for NPO. R1's oxygen saturation level was 71% (a normal blood oxygen level is between 95% and 100%, regardless of age) and was taken to the emergency department (ED) by ambulance. In addition, on 1/27/26 at 12:32 p.m., R3 was seated at a table in the dining room. R3 was eating from a plate that contained a hotdish made from stuffing with chunks of turkey in it. DA-A stated the regular…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-02-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure professional standards of care were followed while waiting for emergency medical services for 1 of 3 residents (R1) reviewed for quality of care. This resulted in harm when a trained medication aide (TMA) and a police officer were awaiting EMS arrival when R1's change in condition worsened and the nurse was not notified. Findings include: R1's care plan since admission dated [DATE] to print date [DATE], identified R1's advanced directive: full code and directed staff follow POLST guidelines. R1 had CHF and directed staff to check breath sounds and monitor/document for labored breathing, use of accessory muscles while breathing, and monitor oxygen settings. R1's quarterly Minimum Data Set, dated [DATE], identified intact cognition and no behaviors. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes mellitus (DM), arthritis, upper impairment of bilateral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a safe transfer for 1 of 3 residents (R3) reviewed for accidents when staff failed to stay next to R3 while in the stand lift and staff walked away from the stand lift to move wheelchair out of the way. Findings include:R3's annual Minimum Data Set (MDS) dated [DATE], identified R3's cognition was moderately impaired with no behaviors. R3 required substantial/moderate assistance with activities of daily living including all transfers. Once standing R3 was dependent upon staff to walk 10 feet with walker and used manual wheelchair for mobility. R3's active diagnoses included progressive neurological condition, osteoporosis (causes bones to become weak and brittle), dementia, Parkinson's disease (a movement disorder of the nervous system that worsens over time and may cause stiffness, slowing of movement and trouble with balance that raises the risk of falls), malnutrition, anxiety disorder, depression, and history of falls without…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-11 · tag F0554 — isolated
    Allow 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 nebulizer medications were administered safely for 1 of 3 resident s (R30) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications.Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 3 resident s (R30) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had severe cognitive impairment and had diagnosis which included Alzheimer's depression, and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). Further, R5 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R30's care plan revised 1/25/26, identified R30 had altered respiratory status/difficulty breathing r/t COPD.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 2 of 2 resident (R21, R5) reviewed for restraints. Findings Include: R21's quarterly Minimum Data Set, dated [DATE], identified R21 had severe cognitive impairment and diagnoses which included: stroke, dementia and arthritis. R21's MDS identified R21 required partial/moderate assistance with rolling left to right and lying to sitting. R21 required substantial/maximal assistance with sitting to standing and transfers. In addition, R21's MDS identified R21 has two or more falls with no injury and restraints were not used. R21's Care Area Assessment (CAA) dated 5/14/25, identified R21 was at risk for falls related to her impaired mobility and cognitive functions and need for activities of daily living (ADL) assistance. R21's CAA did not identify R21 used any restraints. R21's care plan revised 1/26/26, identified R21 was at risk for falls due to spinal…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure that routine shaving was provided for one of two (R18) individuals reviewed for activities of daily living (ADLs) who were dependent on staff for their care. Findings include: R18's brief interview for mental status (BIMS) revealed R18 had severe cognitive impairment. R18 functional abilities and goals (GG) evaluation dated 2/6/26, indicated R18 needed moderate assistance for ADLS and was set up for oral hygiene. R18's functional abilities and goals assessment dated [DATE], indicated R18 needed moderate assistance for ADLs. R18's signed order summary report dated 2/11/26, revealed R18 had a diagnosis of kidney failure, malignant neoplasm of the bladder (bladder cancer), and palliative care. R18 received hydromorphone hydrochloride (HCL) 2 milligrams (mg) two times a day for pain. R18's care plan dated 1/27/26, indicated R18 needed assistance for ADLs. R18's progress notes dated 2/5/26 to 2/10/26 did not identify R18 as refusing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to disinfect a multi-use glucometer (a machine that is used for blood glucose monitoring) after use for 1 of 2 residents (R41) reviewed for blood glucose monitoring. Further the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 3 residents ( R62) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Review of Manufactures guidelines for Assure Platinum multi Blood Glucose Monitoring System (BGMS) revised 9/24, identified disinfecting the glucometer was to be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe, after every resident use. Identified ,what would happen when a blood glucose meter was not cleaned and disinfected after use.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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's administrator failed to provide oversight, develop policies and procedures to ensure emergency responders had access to enter the building when called for emergent resident needs for 1 of 1 resident (R1) reviewed. A police officer (PO) and emergency medical services (EMS) arrived at the facility following a 911 call, were not able timely access the resident by entry to the building and the resident room. Findings include: Review of R1's Provider Orders for Life-Sustaining Treatment (POLST) form signed on [DATE] at 8:34 a.m. identified R1 was a full code, CPR would be started, and the ambulance would be called for transport to the hospital. The 911 call from [DATE] was listened to on [DATE] at 11:19 a.m. at the police department with the chief of police (COP) and identified: the facility nurse identified who she was, name of nursing home and a resident needed to go to ER, full code. Please send someone right away. room [ROOM NUMBER] long term…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner that promoted dignity for 3 of 4 (R2, R3, R4) reviewed. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors. He required supervision/touch assist with all transfers and ambulation up to 10 feet, partial/moderate assistance with toileting, personal/toileting hygiene, and sit to stand, substantial/maximum assist with bathing, and used a walker and/or wheelchair for mobility. He was occasionally incontinent of bladder and always continent of bowel. Diagnoses included stroke, arthritis, dementia, anxiety, and depression. R2's care plan dated 1/29/25, identified he was at risk for falls related to mobility deficits and psychotropic drug use and directed staff to anticipate and meet the needs of the resident, call light place within reach, encourage to use call light for assistance as needed and prompt response…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 provide range of motion (ROM) (refers to how far you can move or stretch a part of your body) services to prevent a potential decrease in range of motion for 1 of 1 resident (R21) reviewed who required range of motion for restorative nursing exercises. Findings include: R21's annual Minimum Data Set (MDS) dated [DATE], indicated R21 was cognitively intact. R21 had a diagnoses which included hemiplegia (a condition caused by brain damage that leads to paralysis on one side of the body,) cerebral infarction affecting the left non-dominant side (stroke), heart failure, and hypertension (high blood pressure). R21 required extensive assistance with bed mobility, transfers, and toileting. R21's Significant Change Care Area Assessment (CAA) dated 10/30/24, indicated R21 was able to voice concerns and preferences and make daily choices. R21 required extensive assistance with activities of daily living (ADLs) which included dressing, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to accurately assess and implement safe smoking interventions for 1 of 1 resident (R6) reviewed for smoking. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had diagnoses which included diabetes mellitus (DM), anemia (a condition where there are lower than normal number of red blood cells in the body), and hypertension (elevated blood pressure). Identified R6 had intact cognition and required extensive assistance from staff with activities of daily living (ADL's) which included transfers and toileting. R6's significant change in status Care Area assessment dated [DATE], identified interventions were in place to address safety needs. R6's care plan dated 4/11/24, identified the facility had determined R6 was safe to smoke independently. Care plan identified a goal that R6 refrained from smoking in inappropriate places. R6's smoking assessment dated [DATE], indicated R6 was safe to light the cigarette,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 4 residents ( R34) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to implement hand hygiene for 3 of 3 residents (R3, R4, R5) observed during medication administration. Findings include: PPE Review of CDC guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · E2023-10-04 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure sufficient staffing to provide routine assistance with activities of daily living (ADL's) for 1 of 1 resident (R11) who was dependent on staff for ADL's. In addition, one resident ( R31) and 3 of 5 of the resident council members (R11, R17 and R1) voiced concerns with an inadequate number of staff to routinely meet their needs in a timely manner. Findings include: R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included Multiple Sclerosis (MS) and depression. Identified R11 was cognitively intact and was dependent upon staff with ADL's of dressing, transferring, and toileting. During an interview on 10/2/23, at 12:38 p.m. R11 indicated call lights were not answered timely and he had to wait an hour or more at times for his call light to be answered. During observations on 10/2/23, revealed the following: - At 12:46 p.m., R11 turned his call light on, stated he had a wet brief and stated…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 1 of 2 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 10/3/23 at 9:50 a.m., laundry aide (LA)-A pushed an uncovered cart that contained personal laundry which consisted of pants and shirts on hangers. Proceeded down the hallway, removed laundry from the uncovered cart and placed in R47's closet. LA-A walked back into the hallway, removed laundry from the uncovered cart and placed in R10's closet. LA-A then pushed the uncovered cart into the elevator and back to the laundry room. During an observation on 10/3/23 at 2:36 p.m., nursing assistant (NA)-B pushed an uncovered cart which contained clean wash…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-04 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 4 of 5 residents (R1, R11, R18 and R31) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Current CDC recommendations 3/15/2023, revealed the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age [AGE] and older, based on shared clinical decision-making, should receive one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Indicated individuals who received PCV13 at any age and PPSV23 before the age of 65 should receive one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R1's facesheet, identified R1, age [AGE] was admitted to the facility on [DATE]. Review of R1's Minnesota Immunization Information Connection (MIIC) undated, identified R1 had received PPSV23 on 1/1/2007, 1/6/2010, 11/23/2015 and received PCV13 on 10/18/2017. R1's medical…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0554 — isolated
    Allow 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 assessed for the ability to self administer medications (SAM) for 1 of 1 resident (R33) reviewed for medication administration. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], indicated R33 was cognitively intact. Identified R33 had diagnoses which included congestive heart failure (CHF), anxiety, depression and required extensive assistance from staff with activities of daily living (ADL's) which included transfers and toileting. R33's signed Physician Orders dated 9/15/23, revealed the following: - Tylenol 650 milligrams (mg) by mouth three times daily, used for pain management. - Coreg 25 mg tablet by mouth two times daily, used for high blood pressure. - Lasix 40 mg tablet by mouth one time daily, reduction of fluid in the body. - Multi-vitamin tablet by mouth one time daily, used for daily supplements. - Potassium Chloride extended release (ER) 20 milliequivalent (mEq) tablets by mouth…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a comprehensive person-centered care plan which included interventions and a goal related to smoking safety for 1 of 1 residents (R47) reviewed for accidents. Findings include: R47's facility admission record dated 9/1/23, identified R47 was admitted on [DATE], with diagnosis which included acquired absence of right ankle and foot, diabetes mellitus (DM), and hypertension (elevated blood pressure). Indicated R47 was a smoker and a smoking assessment had been completed. R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 had intact cognition and required limited assistance from staff with activities of daily living (ADL's) which included transfers and toileting. R47's care plan initiated 9/7/23, lacked documentation of a focus, goals or interventions of R47's smoking plan. During an interview on 10/2/23 at 1:40 p.m., R47 stated he was a current smoker in the facility and had been since admission. During an interview on 10/3/23…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess and monitor for 1 of 1 resident (R33) who was reviewed for non-pressure related skin issues related to a bruise obtained from the patient assisted lift (PAL) for transfers. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], indicated R33 was cognitively intact and had moderate difficulty hearing. Identified R33 had diagnoses which included congestive heart failure (CHF), anxiety, depression and required extensive assistance from staff with activities of daily living (ADL's) which included bed mobility, toileting and was totally dependent with transfers. Further, the MDS identified R33 used a wheelchair to move around the unit. R33's annual Care Area Assessment (CAA) dated 2/6/23, identified R33 had diagnoses which included lower extremity edema, atrial fibrillation (A-Fib), hypertension, chronic kidney disease (CKD), and degenerative joint disease (DJD) of shoulder. Indicated R33 had balance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-04 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 residents (R33) reviewed for hearing. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], indicated R33 was cognitively intact and had moderate difficulty hearing. R33's Care Area Assessment (CAA) dated 2/6/23, indicated R33 had the potential for communication deficits related to her hearing impairment. Identified R33 had poor hearing in both ears and R33 could hear better in right ear. Indicated R33 had a history of cerumen build up. R33's care plan dated 7/27/23, indicated R33 would be referred to audiology for a hearing consult as ordered and directed by resident and/or her representative. R33's electronic health record (EHR) lacked evidence R33 was offered an audiology appointment. During an interview on 10/2/23 at 2:25 p.m., R33's resident representative (RR)-A stated R33 was hard of hearing and was not aware if resident had ever had a hearing exam. RR-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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure safe smoking interventions for 1 of 1 resident (R47) reviewed for smoking. In addition, the facility failed to ensure safe transfers with a patient assist lift (PAL) for 1 of 4 residents (R33) reviewed for accidents. Findings include: R47 R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 had diagnosis which included amputation, hypertension (elevated blood pressure), and diabetes mellitus (DM). Identified R47 had intact cognition and required limited assistance from staff with activities of daily living (ADL's) which included transfers and toileting. R47's admission Care Area Assessment (CAA) identified R47 identified interventions were in place to address R47's safety needs. R47's care plan initiated 9/7/23, lacked a focus, goal, and interventions for R47's smoking practices R47's progress notes dated 9/2/23 at 6:17 p.m., indicated a smoking assessment had been completed. R47's smoking assessment dated [DATE],…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$53,847 in federal fines across 1 penalty.

  • $53,847 — penalty dated 2026-01-28

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 ECUMEN — 5 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 →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 5 of 54.6+0.4 vs chain
Quality measures 2 of 53.2-1.2 vs chain
The other 4 homes this chain runs (chain average 3.4★, 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 / managerTypeRoleShareSince
CDL HOMES, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 06/28/2004
ANDRESEN, ANGELICAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/24/2023
AUGUSTSON, JEANETTEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/18/2022
BERGSTROM, SUSANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/25/2025
CONLIN, JANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/09/2024
FREY, MARYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 08/21/2024
GETAWEH, SHARLENEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/25/2025
HALEY, TAMIIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/18/2022
HARRISON, DOUGLASIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
ISERMAN, BRENTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/25/2025
KENDRICK, SHELLEYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/18/2012
KULL, MARCIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
LAXDAL SOMMER, EMILYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/22/2024
MCALPINE, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/08/2021
OLSON, AMYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2025
PALMER, TINAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/29/2024
PETRABORG, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/21/2013
PLAMANN, JOYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/22/2024
SCHOWALTER, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/21/2025
SCHUNA, PETERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/22/2024
SNYDER, NILSIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 08/21/2024
ANZEL, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/12/2019
BEESON, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/24/2019
BOHLEN, HOLLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/05/2024
COX, NICOLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
DREYER, DOUGLASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2023
GAMST, BLAINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/04/2024
GILLETTE, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/24/2012
HORVATH, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/09/2012
KELLER, KERRIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/06/2013
KEMPER, MONICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2019
KROLAK, JR., THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/24/2025
LEFFNER, JACQUELINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2022
MROSLA, DANIELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
NEWLAND, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/24/2019
OKESON, BRIDGETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/12/1999
OLSON, DANIELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2010
OSMAN, AMALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/14/1995
ROATH, ALVINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2017
SCHUH, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2016
SHOVEIN, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2024
SPEARMAN, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/27/2013
STEVENS, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/14/2010
THOM, JAMIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/22/2001
VANG, KOUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/05/2020
WIK, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2016
WILSON, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/11/1998
BARTNES, JANICEIndividualADP OF THE SNFsince 05/11/1998
HUKRIEDE, CHRISTINEIndividualADP OF THE SNFsince 11/05/2004

CMS files one row per role, so the 123 rows in the source record cover these 49 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$8.0M
Net patient revenuemost recent cost report
-66.5%
Operating marginrevenue minus expenses
$144K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 39%Medicare 12%Other / private 49%

This home reported $144K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$739per resident / day
operating cost
$22,456per month
≈ monthly operating cost
$444per day
avg. revenue, all payers

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

What families pay in MN

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245489. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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