Fairview Care Center
702 10th Avenue Northwest, Dodge Center, MN 55927 · Government - County · 46 certified beds · (507) 374-2578 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- 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 recorded 1 serious finding 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.5% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.0% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 4.9% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 10.0% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 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 | 3.6% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.9% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 2.5% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.3% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.4% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.5% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.8% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 9.4% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.3% | 14.8% | 12.0% | typical |
‡ 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.
54.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.43 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 | 54.9%CMS range 43.8–68.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.7–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 79.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.6–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 46 beds and averages 43.0 residents a day — about 93% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 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 3.45 hrs/resident/day on weekends vs 4.04 on weekdays — 15% thinner on weekends. RN hours go from 0.87 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
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 unchanged from the previous inspection. 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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2025-02-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 comprehensively assess pressure ulcer (PU) development, implement appropriate interventions to prevent PU's and notify the provider of changes for 1 of 3 residents (R1) who entered the facility without pressure ulcers. This resulted in harm when R1 devleoped a stage 3 pressure ulcer. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include Definitions: Blister-a bubble of fluid under the skin. A pressure ulcer can develop into blisters and open sores, which can then become infected and grow deeper until they reach muscle, bone or joints. Stage 3 pressure ulcer is characterized by full thickness skin loss and may be deep. They affect the top two layers of skin and fatty tissue. Unstageable pressure ulcers develop from long-lasting pressure on the skin and means the full depth of the ulcer cannot be measured with slough or eschar obstructing the wound bed. R1's face sheet dated…
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 · D2026-01-14 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide proper updates and notification to a resident representative for 1 of 1 residents (R51) reviewed for representative notification. Findings include:R51's admission Minimum Data Set (MDS) assessment, dated 6/13/25, included R51 was cognitively intact with diagnoses of stroke, hypertension (high blood pressure), depression. R51's consent form dated 6/13/25, listed family member (FM)-B as the first emergency contact and guarantor and FM-A as second emergency contact. Consent form was signed by FM-B. R51's statutory short form power of attorney (POA) document dated 5/16/01, was uploaded to R51's medical record on 6/26/25 at 11:24 a.m. Power of attorney document included FM-A as attorney-in-fact. FM-B was included under successor attorney-in-fact. POA document included a check next to a line of text which read Each attorney-in-fact may independently exercise the powers granted. Only one name, FM-A, was listed under the heading attorney(s)-in-fact. FM-B was listed under successor attorney(s)-in-fact with the statement…
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 before2026-01-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a medication was administered safely for 1 of 1 resident (R42) who had been assessed as unable to safely self-administer medications.Findings include:The annual Minimum Data Set (MDS) assessment dated [DATE] indicated R42's had severe cognitive impairment, required set-up assistance for upper body dressing, partial/moderate assistance for lower body dressing, substantial/maximal assistance with taking on/off footwear, and set-up assistance for eating.R42's medical diagnosis included chronic obstructive pulmonary disease (COPD) (lung and airway disease that restricts your breathing), chronic diastolic heart failure (CHF) (causes shortness of breath and fatigue).R42's orders included Ipratropium-Albuterol inhalation three times per day in the morning, afternoon, and evening; does not self-administer nebulizer.During observation and interview on 1/13/26 at 8:32 a.m., R42 stated staff hadn't returned to take her nebulizer mask off so…
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 · D2026-01-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to develop a person-centered care plan for 1 of 1 resident (R42) reviewed for respiratory cares.Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] indicated R42's had severe cognitive impairment. Further, R42 required set-up assistance for upper body dressing, partial/moderate assistance for lower body dressing, substantial/maximal assistance with taking on/off footwear, and set-up assistance for eating.R42's medical diagnosis included chronic obstructive pulmonary disease (COPD) lung and airway disease that restricts your breathing), chronic diastolic heart failure (CHF) causes shortness of breath and fatigue).R42's care plan failed to include a respiratory care plan. Further, the comprehensive care plan lacked the resident preference to have staff remove the nebulizer mask.R42's orders included Ipratropium-Albuterol inhalation three times per day in the morning, afternoon, and evening; does not self-administer…
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 · D2026-01-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper infection control practices were performed for 2 of 2 residents (R45, R9) who had their blood sugar checks completed with the same glucometer (machine used to check blood glucose).Findings include:R9's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R9 was diabetic.R9's medication administration record indicated R9's blood sugar was checked four times a day.R45's admission MDS dated [DATE] indicated R45 was diabetic.R45's medication administration record indicated R45's blood sugar was checked four times a day: before meals and at bedtime.During observation and interview on 1/13/26 at 4:04 p.m., licensed practical nurse (LPN)-A took a canvas case containing glucometer from the top of the medication cart and entered R45's room. LPN-A opened the case and placed it on R45's bedside table. LPN-A checked R45's blood sugar, placed the glucometer in the case, and left the room, and placed the case in the top…
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 · D2025-07-31 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
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 unqualified staff did not perform ear cleaning for 1 of 4 residents (R1) reviewed for cares provided by unqualified staff.Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated he admitted to the facility on [DATE], and took an antiplatelet medication (medication to prevent platelets from forming blood clots). R1 had an adequate ability to hear, used a hearing aid or other hearing appliance, had moderately impaired cognition, and required moderate staff assistance with personal hygiene. R1's facesheet dated 7/30/25, indicated he had diagnoses which included weakness, unspecified abnormalities of gait and mobility, and weakness. R1's care plan for activities of daily living (ADL's) dated 5/2/25, identified he needed assistance with activities of daily living (ADL)'s. Interventions included: showers with assist of one staff, allow to complete as much as able, resident prefers a shower twice a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-16 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 insulin pens were appropriately labeled according to manufacturer's guidelines with an opened date for 1 of 1 observed medication cart for 1 of 1 resident (R28) who required the use of an insulin pen. Furthermore, the facility failed to ensure tuberculin solution was dated when opened. In addition, failed to ensure expired product was not available for administration for 1 of 1 medication room reviewed for medication storage. This had the potential to affect anyone who would be prescribed this medication. Findings include: During an observation on 1/14/25 licensed practical nurse (LPN)-B removed an insulin pen from the 100 hall cart for R28 and continued to prepare. LPN-B indicated they need to have all insulin verified by a second nurse. While waiting for another nurse, surveyor observed the insulin nearly emptied and found to not have an opened date on the pen. LPN-B said it should be on the plastic cover but was unable to find said cover. LPN-B removed the insulin pen from writers' hand, removed…
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 before2025-01-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess residents for their ability to self-administer nebulizer treatments after nurse set up for 1 of 1 resident (R31) observed self-administrating a nebulizer treatment. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE] indicated R31 was mildly cognitively impaired with a diagnosis of dementia, heart failure, chronic obstructive pulmonary disease (COPD) and asthma. R31's orders included Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters), three times a day related to COPD. R31's care plan included, resident needs assist with ADL's (activities of daily living), is at risk for falls and to keep environment free of clutter, and resident is alert and oriented, due to forgetfulness, staff to anticipate resident needs. While observing medication administration on 1/14/25 at 10:11 a.m. registered nurse (RN)-A had their medication cart in the main entrance area to the left of the 200-hall…
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 · D2025-01-16 · tag F0811 — isolatedEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
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 with difficulty swallowing were assisted with meals by qualified individuals. Findings include: During an observation and interview on 1/13/25 at 5:22 p.m., Activity aide (A)-A was feeding R3 spoon full of food and handing him bites of a sandwich. A-A said she just finished the Paid Feeding Assistant Training. A-A indicated R3 is supposed to be on a pureed diet, but family wants him to have a mechanical soft diet. A-A said R3 aspirates a lot, we give him small drinks and must be assisted by staff. If he feeds himself, he will cough most of the night. R3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had cognitive impairment, lower extremity impairment of one side of the body. R3's diagnoses included stroke, dysphagia (condition affecting ability to swallow), and left-sided hemiplegia (paralysis affecting one side of the body). R3's Medication/Treatment Administration/Order Summary Record reads,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review the facility failed to revise the plan of care after changes to fall prevention measure for 1 of 4 residents (R3) reviewed for accidents. Findings include: R3's Face sheet dated 12/31/24, identified diagnoses of Alzheimer's disease and repeated falls. R3's fall incident report dated 12/6/24, identified R3 had an unwitnessed fall at 7:00 a.m., R3 was found on the floor, leaning against the bed. Injuries of abrasion to right knee, bruise to right lower leg and left forearm. R3's progress notes dated 12/9/24, 12/10/24, 12/11/24, and 12/12/24, identified interdisciplinary team reviewed fall from 12/6/24 and determined to get R3 up if she is restless or trying to kick her legs out of bed. R3's care plan was not updated with this intervention until 12/30/24. R3's mobility focus care plan dated 12/30/24, identified R3 had a history of falls. R3's care plan identified an intervention: If resident is restless while in bed, and/or trying to kick her legs out of bed, she is to get up into her chair and brought out into hallway or dayroom,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to assess and monitor non-pressure related skin injuries (bruises) for changes until resolved for 1 of 3 residents (R1, R2 and R3), reviewed for injury of unknown origin. Findings include: R1's progress note dated 10/30/24 at 8:05 a.m., included R1 had whirlpool this morning. Continue to monitor skin. Various areas of bruising in stages of healing .Skin intact. R1's record did not include an assessment that identified skin integrity of and around the bruise location and size of the bruising and any associated pain. R1's admission, Minimum Data Set (MDS), dated [DATE], indicated R1's cognition was moderately impaired. R1's care plan dated 11/5/24, identified a focus of potential for pressure ulcer development related to impaired mobility, impaired cognition, occasional incontinence, variable intake, and left arm sling use. Interventions included to follow the facility policies for prevention and treatment of skin breakdown. R1's Incident Of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2024-12-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure medications were administered according to physician order for 1 of 1 residents (R5) reviewed for medication errors. Findings include: Syndrome of inappropriate antidiuretic hormone (SIADH)-a condition that occurs when the body produces too much antidiuretic hormone (ADH), also known as vasopressin. ADH is a hormone that helps the kidneys regulate water loss through urine. When there's too much ADH, the body retains water and electrolytes like sodium in the blood fall. A normal blood sodium level is between 135 and 145 milliequivalents per liter (mEq/L). A sodium level below 135 mEq/L is called hyponatremia, or low blood sodium. Severe hyponatremia, defined as serum sodium below 120 mEq/L. R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5's cognition was intact and had diagnoses of chronic kidney disease stage 2 (mild damage), hypoosmolality (a fluid and electrolyte disorder that can occur when there is a loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-11 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to appropriately and timely disposition 95 prescribed medications (over 2000 pills) that had been discontinued to prevent potential diversion that were observed in 1 of 1 medication rooms. Findings include: During an observation and interview on 9/11/24 at 9:48 a.m., of narcotic count with licensed practical nurse (LPN)-A went to locked medication room. There were medications in bubble packs, liquid medications, medications in vials, and inhalant medications on both counters. These medications were in plastic bins, loose on the counters, and in ziplocked bags. During a count of the narcotics in the medication cart eight narcotics were discontinued mixed in with with the medications in use. LPN-A stated narcotics are kept in the medication cart until the Director of Nursing (DON) or assistant DON (ADON) remove them from the cart. Until that point, nursing staff continue to count and keep them with the active narcotics. LPN-A stated nurses would verbally tell the DON or ADON of medications that needed to be…
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 before2024-09-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to place an indwelling urinary catheter correctly in 1 of 3 residents (R1) which resulted in discomfort, bleeding, and emergent services. Finding include: R1's face sheet dated 9/11/24, identified had diagnoses of infection and inflammatory reaction due to indwelling urethral catheter (occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation), chronic kidney disease (gradual loss of kidney function), benign prostatic hyperplasia (enlarged prostate), obstructive and reflux uropathy (when urine is unable to flow normally through the urinary tract from blockage), and history or urinary tract infections (UTI). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment. R1 required maximum assistance with toileting hygiene and had an indwelling urinary catheter. R1's care plan dated 7/3/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-20 · 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 complete comprehensive safety assessments for electric lift recliners to prevent and/or reduce falls from electric recliners for 2 of 3 residents (R1, R2) who had falls from electric recliners. Findings Include: R1 admission record dated 12/10/12, identified R1 had diabetes mellitus with diabetic nephropathy, dementia without behavioral disturbances, general anxiety disorder, and asthma. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment with no behaviors. R1 was frequently incontinent of bowel and bladder and was dependent on staff for transfers, toilet use, personal hygiene, and bathing. R1's MDS identified no falls since admission or previous assessment. R1's flexion, abduction, and external rotation ([NAME]) fall risk dated 10/4/23, identified R1 was at significant risk for falls. R1's care plan dated 7/7/23, identified R1 had an alteration in mobility related to falls risk, impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-13 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 implement the facility's abuse policy/procedures to report and ensure resident protections from suspected or alleged abuse for 1 of 1 resident (R2) reviewed for allegations of abuse. Findings include: The facility policy titled, Abuse Prohibition and Prevention, revised 11/7/22, directed protection-When abuse is suspected or alleged, resident safety is a priority. 1. If witness to a situation, staff shall intervene immediately to remove the person committing the action from the scene and protect the resident from the situation. 2. If an employee is suspected of abuse, the employee shall be placed on administrative leave until completion of the investigation. The policy further directed; all employees of the care center are mandated reporters. All violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately with the following guidelines: within 2 hours for allegations that involve abuse or serious bodily injury,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-13 · 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 ensure witnessed allegations of physical abuse (rough handling) were reported immediately, within two hours, to the State Agency (SA) for 1 of 1 resident (R2) reviewed for allegations of staff to resident abuse. Findings include: Facility reported incident (FRI) submitted on 12/9/23 at 11:55 p.m., identified that on 12/09/23 at 7:45 p.m. nursing assistant (NA)-A stated that while assisting to transfer R2 from bed to wheelchair, they had witnessed NA-B roughly grab R1's wrist to stand her up and get her to cooperate with the transfer it was reported this incident happened around 3:30 p.m. that day and a second incident happened when NA-A again assisted NA-B with putting R1 to bed in which NA-B swung R2's legs roughly into bed. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2's cognition was severely impaired. R2's diagnoses included fractures or other multiple traumas, and depression. Further indicated R2 to have physical and verbal…
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 · F2023-10-19 · 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 and document review, the facility failed to ensure residents received their mail on Saturdays for 2 of 3 residents (R11, and R25) who attended the resident council meeting. This deficient practice had the potential to affect any resident who received mail. Finding includes: On 10/18/23 at 10:36 a.m., during the Resident Council interview, two residents (R11 and R25) indicated they did not receive their mail on Saturdays. Residents R11 and R25 stated they had to wait until Monday for their Saturday mail, and they no longer received their mail on Saturdays. R11's Annual Minimal Data Set (MDS) dated [DATE], indicated intact cognition (able to fully understand). No history of delusions, hallucinations (believing or seeing an untrue reality), or diagnosis of dementia noted (difficulty with memory and brain function) R25's Annual Minimal Data Set (MDS) dated [DATE], indicated intact cognition. No history of delusions, hallucinations, or dementia noted. During an interview on 10/18/23 at 11:15 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure food was labeled, dated, and disposed according to the facility's policy for food storage. This failure had the potential to affect all 45 residents who consumed food prepared from the facility's kitchen. Findings include: During the initial kitchen inspection on 10/16/23 at 02:56 p.m., the following food items in the dietary refrigerator were not labeled, dated or discarded as required by the facility's policy: leftover puree cereal prepared on 10/08/23 and no date of when to discard. large, opened carton of chocolate milk with no dates when opened prepared bowls of lettuce/tomato salad with no dates for when prepared and discard date large container of leftover cheese sandwiches with no dates when prepared and no discard date. raw pork riblets stored in a zip lock bag with no date when removed from the original container and placed in a zip lock bag and no discard date. three large zip lock bag of boiled, peeled eggs with no dates when the eggs had been removed from the original bag and placed in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review the facility failed to ensure the medication cart was locked and secure for 1 of 2 medication carts (Wing One). As a result of this deficient practice the medications in the cart were unsecured and had the potential for loss or misuse. Findings include: During observation on 10/18/23 at 1:30 p.m., the medication cart for Wing One was positioned at the end of the wing where it connected to the day room, near the activity table where a puzzle was being put together. The cart was unlocked, and the nurse was not in sight. During observation on 10/18/23 at 2:00 p.m., the medication cart for Wing One was positioned at the end of the wing where it connected to the day room, near the activity table where a puzzle was being put together. The cart was unlocked, and the nurse was not in sight. During observation on 10/18/23 at 2:35 p.m., the medication cart for Wing One was positioned at the end of the wing where it connected to the day room, near the activity table where a puzzle was being put together. The cart was unlocked, and the nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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
Based on observation, interview, and document, review the facility failed to ensure an agency nurse, on first day at the facility, was oriented to the specifics of the facility to be able to provide safe resident care for residents in one of two wings (Wing One). As a result of this deficient practice the residents had the potential for harm for staff not understanding the facility processes for safe resident care. Findings include: On 10/18/23 at 7:11 a.m., during the medication administration observation, Registered Nurse (RN)-C prepared R5's medications to be administered and was unable to identify the resident to administer the medications. RN-C asked another staff member to identify R5 in the dining area. RN-C was assigned to care for residents located on Wing One. Observation on 10/18/23 at 1:30 p.m., 2:00 p.m., and 2:35 p.m., the medication cart for Wing One was positioned at the end of the wing where it connects to the day room, near the activity table where a puzzle was being put together. The cart was unlocked, and the nurse was not in sight. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review the facility failed to ensure the influenza vaccine was given and/or documented refusal for the 2022 influenza season for 2 of 5 residents (R2, R7). As a result of this deficient practice, the resident who did not received the requested influenza vaccine were at higher risk for contracting influenza and the resident without education was not making an informed decisions about choice to receive the influenza vaccine or not. Findings include: R2's admission Record indicated admission date of 04/04/17, readmission on [DATE] and medical diagnoses included Hemiplegia and hemiparesis following cerebral infarction. Further, a consent form for the 2022 season influenza vaccination documenting the choice YES, to receive the 2022 influenza vaccination. The form lacked documentation the 2022 influenza vaccination was given. During an interview on 10/17/23 at 4:58 p.m., the Infection Preventionist stated the influenza vaccination process at the facility was to have the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · 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 interview and document review, the facility failed to assess for an individualized toileting schedule and failed to implement individualized interventions used to reduce the risk of fall for 1 of 5 residents (R1) who was reviewed for accidents. Findings include: R1's admission Record identified R1 admitted on [DATE], had diagnoses of Parkinson's dementia, dysphagia, Chronic Obstructive Pulmonary Disease (COPD), contusion of the scalp, contusion of the abdominal wall, laceration of the liver, fracture of the first and third lumbar vertebra, fracture of multiple ribs. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had adequate hearing and vision, clear speech, makes self-understood and understands others, had moderately impaired cognition and had no rejection of cares. MDS indicated R1 needed extensive assist of one staff, with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. MDS also indicated R1 had poor balance had a history of three or more falls and was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to complete comprehensive bowel/bladder assessments, failed to develop individualized toileting schedule/program, failed to follow the care plan for toileting to improve, maintain, or reduce the risk for worsening bowel/bladder function for 1 of 1 resident (R1) reviewed for incontinence. Findings include: R1's admission Record identified R1 admitted on [DATE], had diagnoses of Parkinson's dementia, dysphagia, Chronic Obstructive Pulmonary Disease (COPD), contusion of the scalp, contusion of the abdominal wall, laceration of the liver, fracture of the first and third lumbar vertebra, fracture of multiple ribs. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had adequate hearing and vision, clear speech, makes self-understood and understands others, had moderately impaired cognition and had no rejection of cares. MDS indicated R1 needed extensive assist of one staff, with bed mobility, transfers, walking, dressing, toilet use 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ALLEN, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | NO PERCENTAGE PROVIDED | since 01/01/2013 |
| KENWORTHY, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | NO PERCENTAGE PROVIDED | since 01/01/2017 |
| PETERSON, RODNEY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | NO PERCENTAGE PROVIDED | since 01/01/2013 |
| TJOSAAS, TIMOTHY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | NO PERCENTAGE PROVIDED | since 01/01/2014 |
| TOQUAM, RHONDA | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2017 |
| ELLIS, KELLY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2024 |
| DIBBLE, JACQUELYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/15/2024 |
| VENEGA, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/30/2024 |
| ALLEN, JEAN | Individual | ADP OF THE SNF | — | since 02/06/1995 |
| MARQUARDT, SARA | Individual | ADP OF THE SNF | — | since 05/04/2025 |
| MCKENZIE, KYLE | Individual | ADP OF THE SNF | — | since 02/18/2026 |
CMS files one row per role, so the 24 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $50K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245344. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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 →
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