Flagstone
12500 Castlemoor Drive, Eden Prairie, MN 55344 · Non profit - Corporation · 72 certified beds · (952) 942-2100 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 | 23.9% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.1% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.8% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.5% | 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 | 4.7% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.2% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.7% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 5.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 31.2% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.4% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.9% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 74.2% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 16.1% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.8% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.28 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.38 | 1.90 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.5% 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 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.6% 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 69 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% 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 therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.5%CMS range 35.8–53.0 | 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 | 9.3%CMS range 6.3–13.6 | 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 | 53.6% | 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 | 52.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 26.1% | 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 | 98.7% | 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 | 97.4% | 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 | 1.3% | 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 | 6.2%CMS range 3.2–8.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 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 72 beds and averages 67.4 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.23 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.08 hrs/resident/day on weekends vs 4.38 on weekdays — 7% thinner on weekends. RN hours go from 1.34 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2026-03-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 obtain and document informed consent, including an explanation of risks and benefits, for 1 of 5 residents (R43) reviewed for the use of psychotropic medications.Findings include: R43's quarterly Minimum Data Set (MDS) dated [DATE], indicated R43 had both long-term and short-term memory impairment and severely impaired cognitive decision-making skills. The MDS indicated R43 had Alzheimer's disease, anxiety, depression, and a psychotic disorder.R43's order summary dated 3/18/26, indicated R43 had an order for 50 milligrams (mg) of Seroquel (an antipsychotic medication) twice a day for psychosis with a start date of 3/12/26. The order summary also included an order for 25 mg of Seroquel daily for psychosis with a start date of 3/12/26. R43's medical record was reviewed and lacked evidence that consent for the use of the Seroquel at the current dose and frequency was obtained prior to the medication being administered. During an interview on 3/19/26 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.
- Potential for harm · D2026-03-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 instructions for use of multiple as-needed (PRN) psychotropic medications were included, to ensure appropriate administration and minimize the risk of unnecessary medication usage for 1 of 5 residents (R43) reviewed for unnecessary medications. Findings include:R43's quarterly MDS dated [DATE], indicated R43 had both long-term and short-term memory impairment and severely impaired cognitive decision-making skills. The MDS indicated R43 had Alzheimer's disease, anxiety, depression, and a psychotic disorder. The MDS indicated R43 did not have hallucinations, delusions, or rejection of care during the look-back period.R43's care plan dated 2/5/26, indicated R43 had an alteration in mood or behavioral expression as well as dementia with psychotic features. The care plan indicated R43's target behaviors were paranoia, beliefs that weren't real, anger at caregivers and family, physical aggression, and wandering/yelling in the hall at others or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete and comprehensive Minimum Data Set(s) (MDS) were completed for 1 of 5 residents (R4) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified the MDS as an assessment tool that facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. The CMS RAI manual also identified that the RAI process (i.e., MDS) was completed to help evaluate residents' strengths and areas for care planning. R4's annual MDS dated [DATE], included the following information:-Section B- Hearing, Speech, and Vision: indicated B0100 (Persistent vegetative state/no discernible consciousness) was answered as no, so staff were to continue to B0200, Hearing. B0200-B1000, fields regarding R4's hearing, speech, his ability to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., facial hair removal) was provided for 1 of 1 resident (R39) reviewed who was dependent of staff for activities of daily living (ADLs).Findings included:R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had severe cognitive impairment, did not refuse personal cares, and needed setup/cleaning assistance with oral hygiene and personal hygiene. MDS also indicated R39 needed moderate assistance with bathing, dressing, and toileting hygiene.R39's Medical Diagnoses report dated 3/20/26, indicated diagnoses of chronic diastolic heart failure, amnesia, essential hypertension, muscle weakness, and bilateral shoulder pain.R39's care plan dated 3/20/26 indicated R39 was cognitively impaired and was had difficulty in communicating. This care plan indicated the staff will anticipate and meet her needs. R39's care plan also indicated she had self-care performance deficits and needed…
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 before2026-03-20 · 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 observation, interview, and document review, the facility failed to comprehensively assess and, if needed, determine or develop proactive interventions to help address pressure injury risk and prevent skin alteration worsening, after a pressure-induced skin alteration was identified for 1 of 3 residents (R19) reviewed for pressure injuries. Findings include: R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, no rejection of care behaviors, and was diagnosed with heart failure, kidney failure, and diabetes. The MDS indicated R19 had a functional limitation in range of motion to both upper extremities, needed moderate assistance with toileting hygiene, was dependent for bathing, and needed moderate assistance for bed mobility. The MDS indicated R19 was at risk for pressure ulcers and had no current pressure ulcers.R19's order summary dated 6/9/25, included an order dated 6/9/25 to place R19's CPAP or BiPAP on at bedtime, check overnight, remove in the morning, clean 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 before2026-03-20 · 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 interview and document review, the facility failed to ensure safety measure were put in place to prevent accidents for one of two resident (R25) reviewed for accidents who had known fainting episodes, often while on the toilet. Findings include:R25's quarterly minimum data set (MDS), dated [DATE], indicated R25 was admitted to the care facility on 7/26/23 and was cognitively intact. The MDS further indicated R25 required substantial to maximum assistance with dressing, bathing and toileting. During an interview on 3/17 and 10:09 a.m., R25's family member (FM)-A stated she had concerns about R25 being left alone in the bathroom due to her having multiple fainting episodes while on the toilet, stating she believes she had an episode most recently on 3/1/26 while on the toilet. FM-A stated they were not sure what was causing the fainting episodes, but the facility was aware she was having them. R25's care plan, lacked any mention of R25's fainting spells to include interventions for her safety or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 document review the facility failed to ensure residents using a continuous positive airway pressure (CPAP) machine had appropriate orders for use to include equipment settings for 1 of 2 residents (R19) reviewed for respiratory care. Findings include:R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, no rejection of care behaviors, and was diagnosed with heart failure, kidney failure, and diabetes. The MDS indicated R19 had a functional limitation in range of motion to both upper extremities, needed moderate assistance with toileting hygiene, was dependent for bathing, and needed moderate assistance for bed mobility. R19's care plan dated 12/22/25, indicated that staff were to assist R19 in applying his CPAP machine per MD/NP orders. R19's order summary dated 3/17/26, included multiple orders for weekly and daily cleaning and maintenance of R19's CPAP/BiPAP machine. The order summary included an order dated 6/9/25, to place R19's CPAP or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 the consulting pharmacist (CP) identified and acted upon 1 of 5 residents (R5) reviewed who had psychotropic medications without an adequate medical diagnosis for ongoing use. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had severely impaired cognition and was diagnosed with dementia and depression. The MDS indicated R5 did not have hallucinations, delusions, or rejection of care during the look-back period. R5's Medical Diagnosis summary dated 4/14/25, included a diagnosis of dementia with other behavioral disturbance dated 4/14/25, depression, a cognitive communication deficit, and an additional diagnosis dated 6/25/21 for dementia without behavioral/psychotic/mood disturbance or anxiety. R5's care plan dated 10/31/25, indicated R5 received antipsychotic medication for dementia with behavioral disturbance. The care plan indicated R5's 6.25 mg of Seroquel two times a day had been decreased to once a day 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.
- Potential for harm · D2026-03-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 observation, interview and record review, the facility failed to ensure medications were administered at the ordered time resulting in worsened pain for 1 of 1 resident (R25) resulting in a significant medication error. Findings include:R25's quarterly minimum data set (MDS), dated [DATE], indicated R25 was admitted to the care facility on 7/26/23, was cognitively intact, and required substantial to maximum assistance with dressing, bathing and toileting. The MDS further indicated R25 received scheduled and as needed pain medication with a pain rating of 7/10 in the past five days. The national library of medicine reports that withdrawal symptoms from baclofen can start within hours of a missed dose to include rebound muscle spasticity and painful spasms. R25' s orders, printed 3/20/26, indicated R25 was receiving the following medications:Baclofen (muscle relaxant used to treat spasticity, specifically spasms, cramping, and tightness) 7.5 milligrams (mg) three times a day at 7:30 a.m., 1:00 p.m., and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-20 · 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 enhanced barrier precautions (EBP) were followed for 3 of 6 residents (R26, R51, R4) and failed to perform hand hygiene to reduce the risk of the spread of infection to others for 1 of 6 residents (R51) reviewed for infection control practices.Findings include: R26 R26's annual Minimum Data Set (MDS) dated [DATE] identified R26 had intact cognition and was dependent on staff for all personal cares including transfers. R26's diagnoses include obstructive uropathy (blockage preventing normal urine flow) and used an indwelling catheter (tube from bladder to a bag outside the body to drain urine). R26's physician orders (PO) dated 1/6/2026 stated Enhanced Barrier Precautions due to catheter. Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting. R26's care plan dated 4/12/24 included, I…
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 17 citations
- Potential for harm · E2025-07-17 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards of practice were followed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:R1R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.R1's physician order from the medication administration record, dated 1/6/25, indicated Ativan Oral Tablet 0.5 milligrams (Lorazepam). Give 0.5 milligrams by mouth every 6 hours as needed for panic attack. Camera footage dated 6/21/25 at 12:53 a.m., showed registered nurse (RN)-A entered R1's room with a medication cup and spoon. RN-A stated to R1, I think you are describing a lot of tension. This will help, the lorazepam. R1 said Is it like Ativan? I can't have that. RN-A stated the medication was the same as R1's gabapentin order, administered the medication to R1 and immediately left 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 · Ecited before2025-07-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:On 7/17/25 at 8:46 a.m., trained medication assistant (TMA)-A was observed administering medications to R4. TMA-A entered the room and touched R4, assisted her to stand up from her bed and then touched the resident's personal fridge to retrieve some apple sauce. TMA-A did not sanitize her hands before administering the medications to R4. TMA-A administered the medications mixed in applesauce by spoon and handed her a cup of water after every spoonful. After administering the medications, TMA-A used hand sanitizer but then touched her face. TMA-A returned to the medication cart and grabbed an already prepared cup of medications for R1. TMA-A did not sanitize her hands prior to entering R1's room at 8:54 a.m. TMA-A gave R1 her medications one at a time, mixed in applesauce and by spoon. TMA-A did not use hand sanitizer after administering 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 · E2025-01-29 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 were provided a private meeting place without staff present for resident council meetings. This deficient practice had the potential to affect all five residents (R29, R39, R45, R35, and R12) who regularly attended the monthly resident council meetings. Findings include: R29's quarterly Minimal Set Data (MDS) dated [DATE], revealed R29 had mild impaired cognition. R39's annual MDS dated [DATE] ,revealed R29 had no cognitive impairment. R45's annual MDS dated [DATE], revealed R45 had no cognitive impairment. R35's quarterly MDS dated [DATE], revealed R25 had mild cognitive impairment. R12's significant change MDS dated [DATE] ,revealed R12 had no cognitive impairment. During an interview on 1/28/25 at 10:01 a.m., with resident council members R29, R39, R45, R35, and R12 revealed none of the residents had been to a resident council meeting. R29, R39, R45, R35, and R12 indicated they had not been invited to attend a resident council…
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 before2025-01-29 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 personal hygiene for 4 of 4 residents ( R7, R33, R267) reviewed for activities of daily living (ADL)'s. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment and had diagnoses which included renal insufficiency, dementia, and depression. Identified R7 required one person physical assist from staff with personal hygiene. R7's current care plan revised 2/27/24, indicated R7 had deficits with ADL's related to dementia and muscle weakness. Indicated R7 required staff assistance with personal hygiene and preferred to have staff assistance with removing facial hair. R7's annual comprehensive Care Area Assessment (CAA) dated 6/6/24, identified R7 required assistance with ADL's. Identified R7 had an activity intolerance related to weakness, physical limitations and dementia. R7's care sheet undated, identified it was a standard for staff to shave residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-29 · 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 the resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R33, R267, R9) reviewed who had medications in their rooms. R33 R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had no cognitive impairment and diagnoses which included: muscle weakness, depression, and diabetes. R33 required moderate assistance with personal hygiene such as combing hair and shaving. R33's care plan dated 12/26/24, revealed R33 had an activity of daily living (ADL) self-care performance deficits due to encephalopathy, aspiration, urinary tract infection (UTI) dysphasia, and cognitive impairment. R33 wanted to be clean and well-dressed. R33 required one assist for dressing, grooming, and hygiene. The care plan lacked information regarding self-administration of medication or medications that were kept in the resident's room. During an 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.
- Potential for harm · D2025-01-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R62) whose care plan was reviewed. Findings include: R62's significant change Minimum Data Set (MDS)dated 12/24/24, identified R62 had no cognitive impairment and had diagnoses which included depression and malnutrition. R62 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. R62's clinical nutrition assessment dated [DATE], identified R62 was on a regular diet and was independent with eating after set up. R62's care plan revised 12/30/24, identified R62 had limited physical mobility and self-care deficits related to failure to thrive, protein malnutrition and weigh loss. R62's intervention included: R62 needed to get up in her wheelchair for all meals. R62's care sheet dated 1/17/25, identified R62 was to be up in wheelchair for all meals. During an observation on 1/28/25 at 12:20 p.m., nursing assistance (NA)-F entered…
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 · D2025-01-29 · tag F0679 — failed to provide activities — isolatedProvide 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 and engaging activities for 1 of 1 residents (R62) reviewed for activities. Findings include: R62's significant change Minimum Data Set (MDS) dated [DATE], identified R62 had no cognitive impairment and had diagnoses which included depression, failure to thrive and was currently receiving hospice services. R62 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. R62's LTC therapeutic recreation and activities assessment dated [DATE], indicated R62 preferred day/activity room and independent activities in her room. R62's preferences were visits from her daughter, talking with staff, watching television, one to one visits, and activities in a group setting. R62's care plan revised 12/30/24, identified R62 had a long term goal to choose her own activities. R62's careplan further indicated R62 was to be invited to scheduled activities, provided an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-29 · 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 implement interventions for 1 of 1 residents (R17) who had a recent fall with a significant injury in the facility and remained at high risk for falls. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], identified R17 had severe cognitive impairment and had diagnoses which included anxiety disorder, dementia, and left humerus (bone in the arm) fracture. Identified R17 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. Identified R17 had one fall with a major injury since last assessment. R17's significant change Care Area Assessment (CAA) dated 12/27/24, identified R17 had one fall since prior assessment. Identified R17 had a fall while using a standing lift and fractured her left humerus Identified R17 remained at high risk for falls related to dementia, cognitive impairment with agitation and depression. Further identified R17 was now…
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 · D2025-01-29 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 newly admitted residents received 30 day physician visits for the first 90 days for 1 of 1 residents (R30) reviewed for 30 day physician visits. Findings include: R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had no cognitive impairment and had diagnoses which included chronic kidney disease (CKD), an indwelling catheter, and a history of urinary tract infections. R30 required moderate assistance with activities of daily living (ADL's) bathing, transfers, and toileting. R30's facesheet indicated R30 was admitted to the facility on [DATE]. R30's medical record lacked evidence R30 was seen by a physician since admission. During an interview on 1/27/25 at 6:29 p.m., R30 stated he had not seen a physician since he was admitted to the facility. R30 further stated he had requested to see a physician and staff avoided him when he asked. R30 indicated he had seen a nurse practitioner however had wanted to see a physician. During…
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 · D2025-01-29 · 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 interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 2 of 2 residents (R61, R57) identified who did not receive medications as ordered. Findings Include: R61 R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 had moderate cognitive impairment and diagnoses which included: Crohn's disease (chronic condition that causes inflammation of gastrointestinal tract), heart failure and chronic kidney disease. During an observation on 1/27/25 at 4:38 p.m., trained medication aide (TMA)-A set up R61's medications. TMA-A indicated R61 was to receive Creon (medication that replaces digestive enzymes in body) however it was not available to administer, so would contact the pharmacy to order it again. R61's Discharge Orders And Information hospital form dated 12/30/24, included the following: -Creon 24000-76000 units oral capsule, take one capsule by mouth three times daily. R61's January Electronic Medication…
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 · D2025-01-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 had a 7% percent medication error rate for 2 of 4 residents( R61, R44) observed during medication administration. Findings Include: R61 R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 had moderate cognitive impairment and diagnoses which included: Crohn's disease (chronic condition that causes inflammation of gastrointestinal tract), heart failure and chronic kidney disease. R61's Discharge Orders And Information hospital form dated 12/30/24, included the following: -Creon 24000-76000 units oral capsule, take one capsule by mouth three times daily. During an observation on 1/27/25 at 4:38 p.m. trained medication aide (TMA)-A set up R61's medications. TMA-A indicated R61 was to receive Creon (medication that replaced digestive enzymes in body) however it was not available, so she would contact the pharmacy to order it again. R44 R44's admission MDS dated [DATE], identified R44 was cognitively intact, and had diagnoses which…
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 · D2024-03-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure resident room walls were in good repair to create a home-like environment for 1 of 1 resident (R26) reviewed for room environment. Findings include: R26's Optional State Assessment (OSA) dated 2/26/23, indicated severe cognitive impairment, did not reject care, required extensive assist with bed mobility and toileting, and was dependent on staff for transfers. R26's significant change Minimum Data Set (MDS) dated [DATE], indicated it was somewhat important to take care of personal belongings or things, had a wheelchair, was dependent on staff for transfers and wheeling self in the wheelchair. R26's care plan dated 3/1/24, indicated R26 had an alteration in physical mobility and did not ambulate, used a wheelchair to reach all destinations and staff were to assist with mobility as needed. R26's care plan dated 10/6/20, indicated the facility was R26's home and interventions included encouraging R26 to bring personal belongings to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to develop a comprehensive care plan for psychotropic medications that included resident-specific interventions for 1 or 4 residents (R54) reviewed for psychotropic medications. Findings include: R54's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and identified R54 was taking psychotropic medications and an antipsychotic on a routine basis. The MDS indicated R54's diagnoses included Alzheimer's disease (a brain disorder that affects behavior and slowly destroys memory and thinking skills), psychotic disorder (symptoms affecting the mind where someone may lose contact with reality), and legal blindness. R54's Care Area Assessment for cognitive loss and dementia dated 2/20/24, indicated R54 had unclear speech and was rarely understood, and her vision was highly impaired, and staff should tell her prior to touching her for transfers or cares. The CAA indicated R54 had restlessness, agitation, and 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 · Dcited before2024-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide grooming and shaving for 1 of 1 residents (R22) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], R22 had moderate cognitive impairment and required partial to moderate assistance with personal hygiene. R22's diagnoses included depression, anxiety, dementia (a loss of memory, language, problem-solving and thinking abilities), and psychosis (symptoms affecting the mind where someone may lose contact with reality). R22's Care Area Assessment (CAA) for cognitive loss and dementia dated 1/16/24, indicated R22 was residing in the facility for ongoing care related to self-care deficits. R22's CAA for functional abilities indicated she needed assistance for dressing, toileting, bathing, personal hygiene, transfers, eating, bed mobility, and on and off unit locomotion. The CAA indicated the resident was at risk for further…
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 before2024-03-20 · 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 observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 2 residents (R26) reviewed for pressure ulcers. Findings include: A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. An unstageable pressure ulcer is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage…
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 · D2024-03-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 ensure adequate monitoring of orthostatic blood pressures for antipsychotic drug use for 1 of 4 residents (R22) reviewed for psychotropic drug use. Additionally, the facility facility failed to ensure adequate monitoring of weights and fluid status for 1 of 5 residents (R22) reviewed for unnecessary medications. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], R22 had moderate cognitive impairment and received a diuretic (water pill), an antidepressant, and an antipsychotic on a routine basis. R22's diagnoses included high blood pressure, high cholesterol, peripheral vascular disease (a circulation disorder caused by a narrowing of the blood vessels), edema (swelling caused by too much fluid trapped in the body's tissues), depression, anxiety, insomnia (sleep disorder), dementia (a loss of memory, language, problem-solving and thinking abilities), and psychosis (symptoms affecting the mind where someone may lose…
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 · D2024-03-20 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement a system to ensure appropriate follow up on wound culture results to prevent potential inappropriate use of antibiotics and determine whether to use special precautions for 1 of 1 resident (R1). Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was dependent on staff for all activities of daily living (ADLs), had an indwelling catheter, was frequently incontinent of bowels, was at risk for pressure ulcers, and had a stage 4 pressure ulcer (A stage four pressure ulcer is full thickness loss of the skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer). R1's Medical Diagnosis form indicated the following diagnoses: multiple sclerosis, paraplegia,…
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.
Part of a chain
This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.3 | -0.3 vs chain |
| Health inspection | 3 of 5 | 3.4 | -0.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 4 of 5 | 2.8 | +1.2 vs chain |
The other 20 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PRESBYTERIAN HOMES AND SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2021 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 10/24/2019 |
| FLETCHER, JONATHAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2025 |
| PEDERSON, MARK | Individual | CORPORATE DIRECTOR | — | since 12/01/2025 |
| PETERSON, HEIDI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| PHS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2011 |
| MEYER, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2011 |
| MIELKE, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| STINER, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/10/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $1.1M 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 245312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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 →
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