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Viewcrest Health Center

3111 Church Street, Duluth, MN 55811 · Non profit - Church related · 88 certified beds · (218) 727-8801 Medicare & Medicaid certified

Call the home — (218) 727-8801 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citations (F0567, F0568, F0570)Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$71,076 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for mishandling residents’ money or property (F0567, F0568, F0570)
  • it has 1 actual-harm citation
  • inspectors recorded 3 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $71,076 in federal fines (most recent 2026-06-02)

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 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1600 Miller Trunk Hwy Bldg C · (218) 786-5360 · Call to confirm hours
Pharmacy
Shopko1.4 mi
801 W Central Entrance · (218) 727-7139 · Call to confirm hours
Grocery
2701 Piedmont Ave · (218) 722-9665 · Call to confirm hours
Park
2302 23rd St · (218) 730-4300 · Typically dawn to dusk
Place of worship
2415 Ensign St · (218) 722-7537

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 3 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.

Overall rating4★
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 increased19.1%18.2%15.4%worse
Long-stay residents who lose too much weight1.5%4.1%5.4%better
Long-stay residents with a catheter left in their bladder2.9%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.7%2.6%2.0%better
Long-stay residents with depressive symptoms4.1%4.1%6.5%better
Long-stay residents who were physically restrained0.7%0.1%0.1%worse
Long-stay residents with falls causing major injury3.5%4.0%3.3%typical
Long-stay residents whose ability to walk worsened21.2%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.4%12.5%18.9%typical
Long-stay residents given the seasonal flu vaccine95.5%96.1%95.3%typical
Long-stay residents with pressure ulcers6.5%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control29.5%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.4%1.9%1.4%typical
Short-stay residents given the seasonal flu vaccine77.3%82.7%79.4%typical
Short-stay residents rehospitalized after admission14.9%23.5%22.6%better
Short-stay residents with an outpatient ER visit8.5%14.8%12.0%better

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

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

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

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

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

52.0% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.0%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
61.3%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 61.3% 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 93 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNF52.0%CMS range 41.4–63.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.8–16.410.7%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 discharge61.3%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 discharge60.2%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 discharge48.4%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 identified95.6%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 setting94.3%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 discharge90.0%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 stay0.0%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 hospitalization6.7%CMS range 3.3–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 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

0.74
RN hours/ resident / day
0.29
LPN hours/ resident / day
2.41
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.41
RN hoursweekends
52.3%
Total nursing turnover
42.1%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 83.9 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 3.14 hrs/resident/day on weekends vs 3.56 on weekdays — 12% thinner on weekends. RN hours go from 0.88 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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

0
deficiencies at the latest standard inspection (2025-08-21)
5
at the previous standard inspection (2024-07-11)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 14 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-03-21 · 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 interview and document review, the facility failed to follow manufacturer's recommendation on EZ Way sling usage, facility policy, and transfer care plan for 1 of 3 (R1) residents reviewed for mechanical lift transfers. Additionally, the facility lacked a system to assess and document appropriate resident sling size. R1 fell out of the sling, sustained a laceration to the back of her head and was sent to the Emergency Department (ED). The IJ began on 3/13/25 at 11:00 p.m., when R1 fell from a mechanical lift causing a laceration to her head and the liklihood for potnetial serious harm. The administrator and director of nursing (DON) were informed of the IJ on 3/21/25 at 10:30 a.m. The facility had implemented corrective action on 3/14/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: R1's Face Sheet dated 2/4/25, indicated R1 had cerebral palsy, abnormal posture, functional quadriplegia, and scoliosis. R1's annual minimum data set (MDS) dated [DATE], indicated…

    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 · Past Non-Compliance
  • Immediate jeopardy · J2024-05-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 follow medication administration policy for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an immediate jeopardy (IJ) for R1 when LPN-B administered R2's medications to R1, which resulted in severe bradycardia (slower than normal heart rate) for R1 leading to hospitalization and a surgical intervention of a temporary pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 5/7/24, when the facility failed follow medication administration policy when LPN-B administered R2's medications to R1, which resulted in severe bradycardia leading to hospitalization and a surgical intervention of a temporary pacemaker. R1 had previously received her a.m. medications and received all of R2's a.m. medications. The facility had implemented corrective action to prevent…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2026-06-02 · 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 record review the facility failed to follow its policy to adequately supervise 1 of 3 residents (R1) prior to a successful elopement who was reviewed for accidents. R1 eloped from the facility wearing a WanderGuard system, was found four blocks away and was hospitalized with abrasions.Findings include:Upon observation on 6/2/26 at 8:30 a.m. the facilities camera recording revealed at 3:52 p.m. on 5/19/26 the maintenance director checked the WanderGuard that was going to be placed on R1. The WanderGuard set off the door alarm, a staff member in the front office heard the alarm and ran to the door. At 5:35 p.m. R1 walked up to the front door and the magnetic light came on. R1 turned around and walked away. The footage had no audio so it could not be confirmed if the alarm sounded. No staff arrived at the door. At 5:42 p.m. R1 walked up to the door, no staff or visitors were in sight of the [NAME]. R1 opened the door and walked through it taking a left turn and proceeded down…

    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
  • Actual harm · Gcited before2024-02-14 · 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 the care plan was followed to prevent and/or reduce the risk of burns from hot liquid for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained three 2nd degree burns (damage to outer and second layers of skin) to both thighs. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure use of assistive devices/adaptive equipment when dining. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had indicated R1 had Alzheimer's disease, dementia, and severe stage of open angle glaucoma to bilateral eyes. R1 was cognitively intact and needed supervision with eating. R1's care plan revised 6/9/23 indicated R1 needed sippy cups with screw tops to prevent spills. R1's Covered Cup assessment dated [DATE], indicated R1 needed covered mugs for hot liquids due to spilling. R1's meal ticket dated 2/13/24…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-08-29 · 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 ensure proper glove use and hand hygiene was performed during incontinence care and wound care for 2 of 3 residents (R3, R4) reviewed for infection control. In addition, the facility failed to use proper personal protective equipment (PPE) for 1 of 3 (R4) residents reviewed for infection control. Findings include: R3's Face Sheet dated 3/15/24 indicated R3 had orders for wound care to his left lower extremity every three days. On 8/27/24 at 1:11 p.m., registered nurse (RN)-A entered R3's room with a gown and gloves on. RN-A told R3 he was going to change the dressing on his left leg. RN-A used wound cleanser and gauze to cleanse R3's left leg which had multiple open areas. RN-A then removed his soiled gloves, and without performing hand hygiene donned clean gloves. RN-A grabbed calcium alginate (a wound dressing) and cut it to size for the wound on the top of R3's left foot, and applied it to the wound bed. RN-A repeated cutting 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-11 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, leaving 15 hours between the evening and morning meals. This had the potential to affect 93 out of 94 residents who take in sustenance orally. Findings include: During interview on 7/08/24 at 5:19 p.m., R47 stated it has been months since a snack was offered after the dinner meal and before bedtime. R47's quarterly Minimum Data Set (MDS) date 4/16/24, identified intact cognition and a diagnosis of diabetes mellitus. During interview on 7/08/24 at 12:14 p.m., dietary manager (DM) stated mealtimes are 7:30 a.m., 11:30 a.m., and 4:30 p.m. with snacks offered at 2:30 p.m. (siesta snack pass) and 7:30 p.m. (bedtime snack pass). Snack carts are prepared and delivered to the units by kitchen staff. Kitchen staff complete the 2:30 p.m. snack pass and nursing staff complete the 7:30 p.m. snack pass. DM used a snack sheet log to ensure each resident was offered a snack twice a day. During interview on 7/09/24 at…

    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
  • Potential for harm · E2024-07-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 cold beverage items were stored at temperature to prevent foodborne illness. This had the potential to affect 16 out of 94 residents who were served beverages from the dining room beverage cart. Findings Include: On 7/10/24 at 7:28 a.m., dietary aid (AD)-A was preparing five cold beverage carts. Each cart had a bin on the top shelf which contained half gallon containers of assorted milk and juice. One of the five carts also contained milk and juice containers on the second shelf which was not in a bin. Ice was added to all 5 bins containing milk and juice and no ice or other cooling source was applied to the milk or juice on the cart which contained milk and juice on the second shelf. Items on the second shelf included following: -opened whole milk -opened and unopened 2% milk -unopened chocolate milk -opened and unopened almond milk -opened cranberry, pineapple, prune, and orange juice Each juice container stated to refrigerate after opening. On 7/10/24 08:05 a.m., the beverage cart was brought to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · 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 record review the facility failed to ensure nebulized medications were administered safely for 1 of 1 resident (R8) who was observed to self-administer a nebulizer and had not been assessed as safe to do so. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of spastic quadriplegic cerebral palsy (CP), asthma, chronic cough, and shortness of breath. R8 had functional limitations in range of motion of both upper extremities, needed substantial assistance with oral care, and was dependent for hygiene and transfers. R8's care plan dated 4/2/24, identified an alteration in respiratory status related to asthma and spastic CP with interventions for a nurse to administer inhalers and nebulizer's as ordered as R8 was unable to do so for herself. It further identified nursing staff to monitor lung sounds, report concerns, keep head of bed elevated when in bed, and observe for the need for oxygen. An assessment for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (a requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care (PASSAR)) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident's (R30) reviewed for PASARR. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of anxiety, depression, and manic depression (bipolar disease). R30's undated face sheet, received on 7/11/24, identified R30 was admitted to the facility on [DATE], and diagnoses included bipolar disorder, major depressive disorder, and panic disorder. During interview on 7/10/24 1:43 p.m., the director of social services (DSS) reviewed the document labeled PAS in R30's medical record. The PAS document dated 1/8/18, identified Senior LinkAge Line did not complete the PAS and forwarded the PAS…

    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 · D2024-07-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 properly care for oxygen and nebulizer equipment for 1 of 2 residents (R8) reviewed for respiratory equipment to help prevent the potential for infection. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of spastic quadriplegic cerebral palsy (CP), asthma, chronic cough, and shortness of breath. R8's care plan dated 4/2/24, identified an alteration in respiratory status related to asthma and spastic CP with interventions for a nurse to administer inhalers and nebulizers as ordered as R8 was unable to do so for herself, monitor lung sounds, report concerns, keep head of bed elevated when in bed, and observe for the need for oxygen. R8's provider orders dated 9/1/22, identified orders for albuterol sulfate (a medication used to treat and prevent breathing problems) three milliliters (mL) two times daily to be administered via inhalation with a nebulizer (a machine used to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-21 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and document review the facility failed to ensure the dietary manager was certified and credentialed to oversee food services. This had potential to affect all 69 residents, staff, and visitors who consumed food from the ktichen. Findings include: During interview on 9/21/23 at 9:53 a.m. dietary manager (DM)-E stated they had not completed the certified dietary manager course, but was working toward becoming enrolled. The facility was helping to enroll them in the course, but was unsure when that would be. The corporate dietary manager was available by email daily. During interview on 9/21/23 at 10:32 a.m., administrator confirmed DM-E did not have their dietary manager certification or state equivalent and DM-E would start the online program for the dietary manager certification on October 1st. The adminstrator wasnted the dietary manager to get settled in before adding extra work as they are a newer employee. The qualifications of DM-E were requested, but not received.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-21 · tag F0880 — failed to prevent and control infections — widespread
    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 utilize proper hand sanitization after topical medication administration for 1 of 5 residents (R226) observed for medication administration; failed to ensure staff completed proper hand hygiene and glove use during distribution of snacks and meals. This had the ability to affect all 69 residents as well as staff and visitors who consumed food in the facility. Findings include: MEDICATION PASS During an observation on 9/19/23 at 6:39 p.m., licensed practical nurse (LPN)-B entered R226's room and administered three medications orally. LPN-B then applied gloves and administered a topical medication to R226's left calf. When done, LPN-B removed her gloves, did not complete hand hygiene, walked to the medication cart in the hallway, documented the medication administration, and then returned R226's medication tube to the medication cart after placing the tube in a zip lock bag. Without completing hand hygiene, LPN-B placed a medication cup on the cart and began to touch other resident medication cards in 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-21 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    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 had reasonable access to their personal funds after hours and on weekends for 2 of 2 residents (R13, R227) reviewed for personal funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R13 was cognitively intact. During an interview on 9/18/23 at 8:34 a.m., R13 stated they went to accounting when they needed money, but it was difficult to get their money and the facility did not have anyone they could get money from on the weekend. R227's annual MDS assessment dated [DATE], identified R227 was cognitively intact. During an interview on 9/18/23 at 9:23 a.m., R227 stated they kept money in a facility account and indicated they could not get money on the weekend, and if they wanted money on a Saturday, they would have to ask for it on Friday, or wait until Monday. During an interview on 9/20/23…

    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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-21 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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 with trust accounts received quarterly accounting statements for 2 of 2 residents (R227, R13) reviewed for resident funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R13 was cognitively intact. During an interview on 9/18/23 at 8:34 a.m., R13 they handled their own finances and had not received a quarterly account balance statement from the facility. R227's annual MDS assessment dated [DATE], identified R227 was cognitively intact. During an interview on 9/20/23 at 9:17 a.m., R227 stated they did not know how much money they had in their account, but since they didn't think it was very much. R227 did not identify if they received a quarterly statement. During an interview on 9/20/23 at 2:43 p.m., the accountant recently stated and had not sent out resident trust account statements since…

    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
Show the remaining 11 citations
  • Potential for harm · E2023-09-21 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure the surety bond was equal to or greater than the funds entrusted to the facility. This had the potential to impact all 52 current and 47 discharged residents identified as having a trust fund account at the facility. Finding include: The facility Trust Fund Monthly Summary, dated 9/1/23 to 9/20/23, identified the beginning balance on 9/1/23 was16,195.63 and the ending balance for the time period was 15,735.63. The balances were calculated based on account balances for 52 current residents and 47 discharged residents. The Nationwide Mutual Insurance Company dated 9/30/22, identified the facility had a surety bond in the amount of $15,000.00 that went into effect on 10/1/22. During an interview on 9/20/23 at 2:43 p.m., the accountant stated the total account trust balance on 9/20/23, was $15,735.63. The balance was made up of 52 current residents and 47 discharged residents. The facility surety bond to cover resident funds at the facility was for $15,000.00 and the current trust account balance had an excess 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-21 · 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 provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R9, R10, R60) reviewed for immunizations. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of cerebral palsy(A group of disorders that affect movement, muscle tone, balance, and posture). R9's undated immunization record, identified R9 received PPSV23 on 7/26/21, and the PCV13 on 3/31/15. R9's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R9/R9's representative. R10's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of vascular dementia. R10's undated immunization record, identified R10 received the pneumococcal 23 (PPSV23) on 6/25/22 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/04/16. R10's medical record failed to provide evidence 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 the facility provided a home like environment for 1 of 1 residents (R47) reviewed for home like environment. Findings include: During an observation on 9/18/23 at 8:17 a.m., R47 was laying on a bare mattress on her bed. The bed was unplugged and in a low position. During an observation on 9/19/23 at 2:42 p.m., R47 was laying across the foot of the bed and the bed had a flat sheet and incontinence pad and there was not pillow or blanket. The room contained two chairs, and an end table and a call light cord hanging from the wall. There was a stuffed animal on the bed and several others on the floor next to the bed. R47's room lacked any personal clothing or items and the bathroom room was locked. During an interview on 9/19/23 at 3:20 p.m., RN-A identified R47 was at the facility for six months. The facility was concerned about hoarding, but R47 had a history of eating things like incontinence briefs and gloves, the facility did not keep things in R47's room. RN-A didn't know why R47 did not have 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the care plan was revised to reflect newly assessed needs and services for 1 of 4 residents (R10) reviewed for changes in activities of daily living (ADL); 1 of 2 residents (R61) reviewed for pressure ulcers. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment. Diagnoses included dementia, kidney disease, history of stroke and anxiety. R10 required limited assistance with bed mobility, transfers, and toileting. Ambulation and dressing did not occur. R10 was frequently incontinent of bowel and always incontinent of urine. R10's care plan dated 8/23, identified staff were to ambulate R10 daily with assist of one and a full wheeled walker. R10's care plan did not address her assessed need for assistance with bed mobility and dressing. During continuous observation on 9/20/23, from 8:20 a.m. to 11:45 a.m. R20 was observed dressed in a hospital gown lying in bed on her…

    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 · D2023-09-21 · 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 provide assistance with toileting for 1 of 2 residents (R10) reviewed for activities of daily living and who were dependent on staff for their care. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment, required limited assistance with toileting, and was always incontinent of bladder. R10's care plan dated 8/23, identified R10 required assistance to change her brief and provide peri cares after each incontinent episode. Interventiions included: staff to remind and assist R10 to the toilet on arising at 6:00 a.m. and every two to three hours during the day, as well as at bedtime; assist R10 to the commode every day around 9:00 a.m., and after breakfast to promote continent bowel movements. On 9/20/23, R10 was continuously observed from 8:20 a.m. until 11:30 a.m. R10 was lying in her bed with the head of her bed elevated, watching her television. R10 remained lying in her 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 · D2023-09-21 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 meaningful activities for 1 of 3 residents (P10) who was dependent on staff for activities. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment and required assistance from staff for most of her activities of daily living (ADLs). R10's Activity assessment dated [DATE], identified current and past activities of fishing, bingo, knitting, watching soap operas, news, a love of animals and birds, and gardening. R10 had children and her previous occupation was office work. R10's care plan dated 8/23, identified she preferred to engage in individual activity. Interventions included 1 to 1 visits two to three times per week, arrange to transport to and from activities of her choice, document attendance and level of participation, and encourage R10 to attend activities. R10 participated in her 1 to 1 visits, occasional bingo, pastoral visits, volunteer visits, music groups…

    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 · D2023-09-21 · 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 recognize positioning needs for 1 of 1 resident (R23) reviewed for positioning; and failed to implement and track a fluid restriction for 1 of 2 residents (R66) reviewed for fluid intake. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified diagnoses of hemiplegia and hemiparesis of left non-dominant side (weakness and loss of movement on one side of the body) due to a stroke. R23 had moderate cognitive impairment, required extensive assistance to complete transfers and self-cares, and used a wheelchair. R23's care plan dated 8/22/22, identified R23 used a Broda wheelchair (wheelchair with increased padding on right and left side that can tilt), their left arm was to be supported on an arm rest when in their wheelchair, and they required assistance with wheelchair mobility. R23's incident report dated 9/13/23, identified R23 had a bruise above their right eyebrow measuring 2 centimeters (cm) x 2 cm and R23…

    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 · D2023-09-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 R23: R23's annual MDS dated [DATE], identified a diagnoses of hemiplegia and hemiparesis of left non-dominant side (weakness and loss of movement on one side of the body) due to a stroke. R23 had moderate cognitive impairment, required extensive assistance to complete transfers and self-cares, and used a wheelchair. R23 was identified to be at risk of skin breakdown with identified treatments of a pressure reducing device for their chair and bed. R23's care plan dated 8/22/22, identified R23 used a Broda wheelchair (wheelchair with increased padding on right and left side that can tilt), a pressure reducing cushion was to be used at all times, their left arm was to be supported on an arm rest when in their wheelchair, and they required assistance with wheelchair mobility. During observation on 9/19/23 at 1:35 p.m., R23 was seated in a Broda wheelchair leaning to the right, left arm was propped on a padded arm tray, blanket was in her right arm, and no cushion was visible in the wheelchair. During observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · 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 ensure an ordered ambulation range of motion (ROM) program was implemented for 1 of 2 residents (R10) reviewed for rehabilitation and restorative nursing. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment, required limited assistance for her daily activities of daily living (ADLs) and ambulation had not occurred. R10's care plan dated 8/23, identified R10 would walk with the use of assistive devices and would not have a decline in walking. Staff were directed to walk R10 with a transfer belt, physical support, and full wheeled walker. R10 was at risk for a decline in ambulation related to her poor balance and cognition. Restorative staff were directed to ambulate R10 50 feet daily with a two wheeled walker and wheelchair follow. During observations on 9/19/23, between 2:15 p.m. and 6:30 p.m. R10 was observed lying on her back in bed. During continuous observation 9/20/23,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 for dementia related behaviors and identify the least restictive intervention(s) and provide ongoing reassesment and care planning for 1 of 1 residents (R47) reviewed who had not personal items in their room. Findings include: R47's annual Minimum Data Set (MDS) dated [DATE], identified R47 had short and long term memory problems and were unable to complete a cognitive assessment. R47 had no identified behaviors including hallucinations or dellusions. R47 required extensive assistance for most activities of daily living and was incontinent of bowel and bladder. R47 took an antidepressant and an antipsychotic and had a diagnosis of dementia. During an observation on 9/18/23 at 8:17 a.m., R47 was laying on a bare mattress on her bed. The bed was unplugged and in a low position. During an observation on 9/19/23 at 2:42 p.m., R47 was laying across the foot of the bed and the bed had a flat sheet and incontinence pad…

    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 · D2023-09-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 anticoagulant side-effect monitoring for 1 of 1 resident (R23) reviewed for anticoagulant use. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified a diagnoses of hemiplegia and hemiparesis of left non-dominant side (weakness and loss of movement on one side of the body) due to a stroke. R23 had moderate cognitive impairment and an anticoagulant was used during the last seven days prior to the completion of the MDS. R23's care plan dated 8/22/22, failed to identify R23's interventions related to anticoagulant use. R23's facility incident report dated 9/13/23, identified R23 was noted to have a bruise above their right eyebrow measuring 2 centimeters (cm) x 2 cm and R23 stated they bumped their head on the bed rail in the night and no staff or other resident hit them. The report identified the resident frequently leans to the right and the root cause of the injury was an unpadded bed rail and did not…

    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.

    Pharmacy Service 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

$71,076 in federal fines across 5 penalties. 1 Medicare payment denial on record.

  • $19,635 — penalty dated 2026-06-02
  • $17,345 — penalty dated 2025-03-21
  • $10,839 — penalty dated 2024-07-11
  • $14,433 — penalty dated 2024-05-14
  • $8,824 — penalty dated 2024-02-14
  • Medicare payment denial — starting 2026-07-02 for 5 days

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 ST. FRANCIS HEALTH SERVICES — 14 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 52.8+0.2 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 4 of 54.6-0.6 vs chain
Quality measures 4 of 52.9+1.1 vs chain
The other 13 homes this chain runs (chain average 2.8★, 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 / managerTypeRoleSince
ST. FRANCIS HEALTH SERVICES OF MORRIS, INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2025
DRIPPS, DANIELIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016
EHLERS, DOUGLASIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
GOODNOUGH, JENNIFERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
GRAMM, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
LAIR, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
LIENEMANN, STEVENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
LUETMER, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
MARLOW, JINAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/06/2022
NELSON, PATRICKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
RENTZ, LAURAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
RENTZ, PAULIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
SCHNEIDER, TODDIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2013
WIESE, LORRAINEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2017
BACH, CURTISIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2024
RAW, CAROLIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/16/2005
PETERSON-DEVRIES, CAMIIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/08/2022
BIG STONE THERAPIES, INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/03/2015
EIDE BAILLY LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2023
BARRY, HEIDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2023
BOYUM, BRITNEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2012
BURROWS, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2024
CASPERS, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/29/2014
EDIN, COLTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
FISHEL, CHESTERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/1998
GRANHEIM, KASCIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/20/2023
HANNEKEN, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/20/2022
HEJHAL, ROXANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/10/2023
HOFMANN, REEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/08/2023
LAFLAMME, DARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/02/1990
LETICH, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2023
OLIPHANT, MIRANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/23/2015
RENTZ, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/22/2024
RYAN, BENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/27/2012
RYAN, GEOFFREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/1998
STOCK, KELSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2022
TEPOVICH, NICHOLASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2024
THOMPSON, RENEEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/10/2018
TOMOSON, APRILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/12/2021
WALKER, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/13/2024
WICK, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
WOLF, JORDANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
CHRISTENSEN, DREWIndividualADP OF THE SNFsince 02/19/2024
SLIVENSKY, JANEIndividualADP OF THE SNFsince 06/20/2022

CMS files one row per role, so the 115 rows in the source record cover these 44 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.2M
Net patient revenuemost recent cost report
-6.9%
Operating marginrevenue minus expenses
$457K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 5%Other / private 38%

This home reported $457K 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

$487per resident / day
operating cost
$14,811per month
≈ monthly operating cost
$456per 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 245414. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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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