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Aurora On France

6500 France Avenue, Edina, MN 55435 · Non profit - Corporation · 65 certified beds · (952) 848-8865 Medicare & Medicaid certified

Call the home — (952) 848-8865 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Sep 2024Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • 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)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — 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.

4/5
CMS overall
4 of 5
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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6405 France Ave S · (952) 929-6994 · Call to confirm hours
Pharmacy
6525 France Ave S · (952) 345-0035 · Call to confirm hours
Grocery
324 Southdale Center · (952) 697-4200 · Call to confirm hours
Park
4300 66th St W · (952) 826-0367 · Typically dawn to dusk
Place of worship
Dr Don0.4 mi
6750 France Ave S · (952) 401-4501

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
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 held steady at 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
Short-stay residents who newly got an antipsychotic medication0.8%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine73.8%82.7%79.4%typical
Short-stay residents rehospitalized after admission31.7%23.5%22.6%worse
Short-stay residents with an outpatient ER visit11.7%14.8%12.0%typical

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.

56.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 560 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.0%U.S. median 51.5%
Got home and stayed home
9.0%U.S. median 10.7%
Went back to hospital
67.9%U.S. median 56.6%
Met the expected recovery
1.22U.S. median 0.31
Therapy hours / resident / day
0.53hours / resident / day
Physical therapy
0.65hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 67.9% 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 246 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 1.22 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.0%CMS range 52.6–58.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 7.3–11.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.9%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 discharge58.5%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 discharge61.4%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 identified99.5%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 setting98.8%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 discharge97.5%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 stay0.8%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 worsened1.9%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 hospitalization4.8%CMS range 3.1–7.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

2.53
RN hours/ resident / day
0.66
LPN hours/ resident / day
3.08
Aide hours/ resident / day
6.27
Total nurse hours/ resident / day
1.94
RN hoursweekends
29.1%
Total nursing turnover
35.6%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 58.2 residents a day — about 90% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.53 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.08 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 5.63 hrs/resident/day on weekends vs 6.53 on weekdays — 14% thinner on weekends. RN hours go from 2.77 to 1.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below 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

8
deficiencies at the latest standard inspection (2026-05-28)
4
at the previous standard inspection (2025-05-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Dcited before2026-05-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote and maintain dignity for 1 of 3 residents reviewed for dignity (R29) when staff directed a continent resident to roll over and have a bowel movement in his brief rather than assessing and implementing toileting interventions consistent with his needs, preferences, and dignity. The facility failed to ensure assessments, care plans, and staff practices provided clear direction regarding R29's toileting status and preferences, despite documentation identifying him as continent of bowel and bladder and his expressed distress regarding having bowel movements in bed. This had the potential to cause psychosocial harm, loss of dignity, and diminished quality of life by failing to respect the resident's autonomy, preferences, and right to receive care in a dignified manner. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview 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 · D2026-05-28 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow resident to safely administer own medications for 1 of 1 (R1) resident observed with medications at bedside. Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, needed substantial/maximal assistance with toileting hygiene, upper/lower body dressings, bed mobility, transfers, and needed moderate assistance with oral and personal hygiene. R1 was dependent on staff for bathing. R1's diagnosis report dated 5/28/26, indicated diagnosis of pneumonia, acute respiratory failure with hypoxia, hypertensive heart failure, diabetes, anxiety disorder, and chronic low back pain. R1's physician orders dated 5/28/26 included orders for clobetasol propionate external ointment 0.05% (a topical steroid) with directions to apply to labia, distal left wall topically in the evening every Monday, Wednesday, Friday 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 · D2026-05-28 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer a written notice of transfer which included a statement of the resident's appeal rights and the contact information of the Office of the State Long-Term Care Ombudsman. In addition, the facility failed to provide written information on the duration of the bed-hold, and reserve bed payment for 2 of 3 residents (R51, R69) reviewed for hospitalizations. Findings include: R51 R51's admissions Minimum Data Set, dated [DATE] identified R51 with intact cognition, had no functional impairment, required assistance with toileting, dressing, and showering. In addition, R51 had diagnoses of congestive heart failure, heart disease, arthritis, depression, and chronic lung disease. During record review of R51's electronic medical record (EMR) R51 was hospitalized on [DATE] following a fall in his room. He was sent to the hospital and remained until 5/18/26 when he was transferred back to the facility. During interview with registered nurse (RN)-A on 5/28/26 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-28 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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 discharge return anticipated (DRA) Minimum Data Set (MDS) was transmitted for 1 of 3 residents (R42) and a discharge return not anticipated (DRNA) MDS was transmitted for 1 of 1 residents (R8), to the Centers for Medicare and Medicaid (CMS) reviewed for no MDS record in 120 days.Findings include: R42's admission MDS dated [DATE], indicated R42 had a discharge- return anticipated and it was unplanned. The MDS indicated the assessment was completed but did not indicate the assessment was submitted to CMS. The MDS included under the submit section, do not submit to CMS. R42's Census listing dated 12/11/25, indicated R42 admitted to the nursing home on [DATE], and their status changed to STOP BILLING on 12/11/25. R42's progress note dated 12/11/25 at 2:56 a.m., indicated R42 was discharged to the emergency department due to a fall. R8's DRNA MDS dated [DATE], indicated R8 had a discharge- return not anticipated and it was planned. The MDS…

    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 · D2026-05-28 · 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 (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R45) reviewed for PAS.Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], indicated R45 was admitted to the facility on [DATE] and had intact cognition. The MDS indicated R45 was diagnosed with anxiety and bipolar disorder. R45's PAS notice dated 4/22/26, indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing facility. R45's medical record was reviewed and lacked evidence that a final determination from the lead agency had been received. During an interview on 5/27/26 at 2:13 p.m., the admissions coordinator (AC) stated that when a resident was admitted from the hospital, the hospital would complete a PAS, and the screening would then be sent 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-28 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 routine/as-needed nail trimming and cleaning was completed for 1 of 1 residents (R13) reviewed for nail care who required staff assistance with their activities of daily living (ADLs).Findings include: R13's admission Minimum Data Set (MDS) 4/10/26, indicated R13 had intact cognition and was diagnosed with paraplegia (the partial or complete paralysis of the lower half of the body) and not diabetes. The MDS indicated R13 required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R13's care plan dated 4/6/26, indicated a weekly body audit was to be performed. The care plan indicated R13 required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement hospital discharge recommendations and facility standing orders for daily weight monitoring for a resident with a primary diagnosis of congestive heart failure (CHF). The facility also failed to assess and implement a low-sodium diet recommendation, failed to monitor for weight changes indicative of fluid retention, and failed to develop a care plan addressing CHF management after the resident's diuretic therapy was placed on hold pending further clinical evaluation for 1 of 1 residents (R84) reviewed for quality of care.Findings include: Findings include:R84's admission Minimum Data Set (MDS) assessment, dated 5/5/26, identified R84 had mild cognitive impairment and a primary diagnosis of chronic congestive heart failure (CHF - a condition where the heart cannot pump blood well often resulting in excess fluid buildup in the body).R84's electronic medical record (EMR) revealed a documented weight of 270 pounds on 5/4/26.R84's hospital…

    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 · D2026-05-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide pharmaceutical services that ensured medications were available to meet residents' needs for 2 of 5 residents reviewed for medication administration (R29 and R57). This deficient practice resulted in multiple prescribed medications being unavailable for administration and created the potential for residents to miss ordered medications or receive doses that differed from the physician's prescribed regimen. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R57's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. During observation and interview on 05/27/2026 at 8:01 a.m., RN-E conducted a medication pass for R29 and identified four…

    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
  • Potential for harm · Fcited before2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 record review, the facility failed to ensure food was properly stored in refrigeration units. In addition the facility failed to ensure dishes were properly air dried prior to stacking for storage. These deficient practices had the potential to impact all residents who consumed facility prepared food. Findings include: During a kitchen tour on 5/19/25 at 2:27 p.m., led by the culinary manager (CM) the following were noted: ---The bottom 3 racks on the right of the walk-in freezer were less than 6 inches from the floor of the freezer and held food. The middle rack bottom shelf touched the floor. There was a prep pan of raw whole turkeys on it. The prep pan had a brownish red substance on the bottom of the pan. ---The first-floor fridge had a stack of boxes sitting directly on the fridge floor. The CM stated they had just got a shipment, and the boxes were still being put away. ---On the clean side of dish room there were 18 stacks of plastic glasses that had visible moisture between and in the glasses. The CM stated the glasses had been stacked…

    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 · Ecited before2025-05-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure staff adhered to infection control standards including the use of personal protective equipment (PPE) in enhanced barrier precaution (EBP) and contact precaution rooms, as well as failing to properly perform hand washing and gloving for 3 of 3 residents (R208, R23, R259) reviewed for infection prevention and control. Findings include: R208: R208's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses including non-pressure chronic ulcer of other part of the right foot with necrosis of muscle, gangrene, cellulitis of right lower limb, osteomyelitis, diabetes mellitus, peripheral vascular disease (PVD), chronic kidney disease. The MDS indicated R208 needed moderate assistance of one person for transfers, was taking antibiotics, and had been participating in occupational and physical therapy. R208's provider order dated 5/9/25 included an order for wound care to her right foot. And on 5/6/25, an order for physical…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-05-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure care was provided to preserve dignity for 2 of 2 residents (R20, R307) who were reviewed for dignity. Findings include: R20: R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated R20 was moderately cognitively impaired with the diagnoses of hyperlipidemia, asthma, depression, anxiety, and diabetes. R20's care plan last revised 5/21/25, indicated R20 required an assist of one personal hygiene. The care plan also indicated R20 had impaired vision and instructed staff to make sure R20's glasses were clean and to remind R20 to wear their glasses. During an observation on 5/20/25 at 9:10 a.m., R20 was noted to have several long hairs on their chin. R20 stated they had not noticed they had chin hairs, and stated if they had known they would want the hairs pulled out. R20 stated staff had not asked if the chin hairs bothered them or offered to assist with removing them. During an observation at 5/21/25 on 9:28 a.m., R20 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-22 · 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 implement new orders for 1 of 1 resident (R26) with fluid retention and failed to recognize hypertensive blood pressure readings and follow provider orders for as-needed (PRN) blood pressure medication for 1 of 1 resident (R307) reviewed with hypertension. Findings Include: R26: R26's admission MDS (Minimum Data Assessment) dated 5/12/25, indicated R26 was cognitively intact and had diagnoses of cardiorespiratory (heart & lung) conditions, coronary artery disease, heart failure, hypertension, diabetes mellitus, and respiratory failure. R26's care plan dated 5/16/25, indicated diuretic therapy, congestive heart failure intervention such as assessments, monitored labs, documented weights, recorded fluid amounts, and administered cardiac medications. R26's provider orders identified the following: -5/7/25 give furosemide (a medication used to rid the body of excess fluid) 80 milligrams (mg) in the morning, and 40 mg later in the day 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report immediately, no later than 2 hours, to the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident abuse for 1 of 3 residents (R5) who were reviewed for allegations of abuse. Findings include: R5's admission Minimum Data Set (MDS) assessment dated [DATE], identified R5's cognitive status was unable to be determined and had diagnoses which included stroke, hypertension (elevated blood pressure), and aphasia (a language disorder that affects a person's ability to understand and communicate language.) Identified R5 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R5's care plan revised 9/16/24, identified R5 was at risk for vulnerability related to recent placement and R5 would remain free from any physical, mental and emotional harm. Care plan directed staff to cue and intervene as needed for safety. During an…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to complete an investigation and ensure protection for residents following an allegation of a staff to resident abuse for 1 of 3 residents (R5) investigated for abuse. Findings include: R5's admission Minimum Data Set (MDS) assessment dated [DATE], identified R5's cognitive status was unable to be determined and had diagnoses which included stroke, hypertension (elevated blood pressure), and aphasia (a language disorder that affects a person's ability to understand and communicate language.) Identified R5 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R5's care plan revised 9/16/24, identified R5 was at risk for vulnerability related to recent placement and R5 would remain free from any physical, mental and emotional harm. Care plan directed staff to cue and intervene as needed for safety. During an interview on 9/23/24 at 11:52 a.m., family member (FM)-A stated on 8/8/24, R5…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all 42 residents. Findings include: During observation and interview on 6/17/24 at 6:36 p.m., dietary (DA)-A loaded silverware, forks, and spoons in the dish washer. The dish washer temperature was 142 for wash cycle and 188 for rinse. Trays went through the washer, and the wash temperature was 142 and rinse temperature was 188. Plates went through the washer, and the washer temperature was 140 and the rinse temperature was 190. Items washed were being placed or stacked for later use. DA-B and DA-A referred to director of culinary (CD) and dining room coordinator (DRC) when asked about the dish washer temperatures. During subsequent observation and interview, CD stated the dish machine was a heat machine and a chemical rep comes out once a month. Dish detergent and dish rinse aid were observed to be attached to the dish machine. DRC stated they regularly put…

    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 · D2024-06-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure comprehensive care plans were developed for montioring side effects in 2 of 5 residents (R4, R147) reviewed for antipsychotic drug use. Findings include: R147 had a diagnosis of dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R147's physician's orders dated 6/12/24, indicated quetiapine fumarate (Seroquel) oral tablet 25 milligrams (mg). Give 12.5 mg by mouth as needed for anxiety twice a day. R127's care plan lacked any indication of side effect montioring for antipsychotic medications. During interview on 6/20/24 at 9:50 a.m., the director of nursing stated residents who were taking an antipsychotic medication should also be monitored for side effects (on the care plan). During interview on 6/20/24 at 10:57 a.m. the Pharmacist stated she had made a recommendation on 6/18/24 to monitor for side effects, add non pharmacological interventions for psychotropics and monthly…

    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 · D2024-06-20 · 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 Based on observation, interview, and document review the facility failed to develop and implement interventions to prevent pressure ulcers. The facility further failed to ensure residents with current pressure ulcers were turned and repositioned timely for 1 of 2 residents (R13) reviewed for pressure ulcers. Findings include: R13's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and a diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, chronic pain, and polyneuropathy. It further indicated R13 had impairment on both sides of upper and lower extremities, required substantial/maximal assistance with bed mobility, and was at risk for and had (1) unstageable facility acquired (not present on admission) deep tissue injury. R13's care area assessment (CAA) for skin was triggered and indicated the following: -at risk for skin breakdown due to decreased mobility, decreased range of motion (ROM) to upper/lower…

    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 · D2024-06-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a Foley catheter was removed according to physician orders for 1 of 1 resident (R4) who was admitted to the facility with an indwelling Foley catheter. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was dependent on staff for toileting hygiene, toileting transfers, had an indwelling catheter. R4's Medical Diagnoses form indicated the following: unspecified fracture of the lower end of the left femur (thigh bone), periprosthetic fracture (fracture around a joint replacement prostheses) around unspecified internal prosthetic joint, and retention of urine. R4's hospital encounter summary dated 5/14/24, indicated R4 had postoperative urinary retention and a history of urinary incontinence and failed a voiding trial on 5/9/24, and a catheter was replaced on 5/10/24. Further, the hospital discharge orders indicated a trial of voiding at the transitional care unit (TCU) in 5 days, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure residents that were prescribed psychotropic medications were monitored for side effects, for 2 of 5 residents (R4, R147) reviewed for unnecessary medications and the facility failed to ensure non pharmacologic interventions were in place for R4 who had psychotropic medications ordered. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 admitted to the facility on [DATE], had intact cognition, did not have behaviors, did not reject care, had depression, and took an antidepressant 7 out of 7 days. R4's Care Area Assessment (CAA) dated 5/20/24, indicated R4 had depression and took fluoxetine 40 mg every day and had an order for trazodone for insomnia and had not used the medication. Further, the CAA indicated, adverse consequences of antidepressants exhibited by R4 included an increased risk for falling and depression. R4's care plan dated 5/23/24, indicated R4 would remain free of signs and symptoms of distress,…

    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
  • Potential for harm · Dcited before2024-06-20 · 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 interview, observation, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) for 1 of 3 (R4) residents who had a Foley catheter reviewed for infection prevention and control. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was dependent on staff for toileting hygiene, toileting transfers, had an indwelling catheter. R4's Medical Diagnoses form indicated under a heading, Special Instructions, EBP-Foley. Additionally, R4's diagnoses included: unspecified fracture of the lower end of the left femur (thigh bone), periprosthetic fracture (fracture around a joint replacement prostheses) around unspecified internal prosthetic joint, and retention of urine. R4's Physician Orders form lacked information under the heading Special Instructions. Additionally, an order dated 6/10/24, indicated the following: • Change catheter and overnight bag every month and as needed unless otherwise directed. R4's care plan…

    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 · D2024-06-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 resident (R2, R16, R27) were offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC Pneumococcal Vaccine Timing for Adults dated 3/15/23, indicated adults 65 years or older should make sure residents were up to date with pneumococcal vaccination according to the following vaccine schedules: -If residents had no prior vaccines, option A was to receive PCV20 and option B was to receive PCV15 and then PPSV23 one year or more later. -If residents had PPSV23 only at any age, option A was to receive PCV20 one year or more later and option B was to receive PCV15 one year or more later. -If residents had PCV13 only at any age, option A was to receive PCV20 one year or more later and option B was to receive PPSV23 one year or more later. -If residents had PCV13 at any age and PPSV23 at less than [AGE] years old, option A was to receive PCV20 5…

    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 · D2024-06-20 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 1 of 5 residents (R16) reviewed for immunizations. Findings include: Center of Disease Control and Prevention (CDC) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States reviewed 4/4/24, directed the following guidance: For people 12 years or older who are not moderately or severely immunocompromised: -unvaccinated= 1 dose of an updated (2023-2024 Formula) mRNA COVID-19 vaccine OR 2 doses of updated Novavax vaccine. -Previously received 1 or more Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of Original monovalent Novavax vaccine, alone or in combination with any Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of [NAME] vaccine, alone or in…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to EBENEZER SENIOR LIVING — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.5+0.5 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 5 of 54.2+0.8 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 5 homes this chain runs (chain average 3.5★, 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
PIPER, KENNETHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/31/2022
CARLSON-WEINBERG, SUSANIndividualCORPORATE DIRECTORsince 05/31/2019
FAUST, KIMIndividualCORPORATE DIRECTORsince 09/21/2021
KVENVOLD, GAYLEIndividualCORPORATE DIRECTORsince 05/23/2024
LANDREVILLE, MARKIndividualCORPORATE DIRECTORsince 02/21/2024
MILIUS, MARGARETIndividualCORPORATE DIRECTORsince 02/21/2024
WALKER, ROBERTIndividualCORPORATE DIRECTORsince 05/31/2022
WORDELMAN, SCOTTIndividualCORPORATE DIRECTORsince 08/24/2017
ANDERSON, BRETTIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 09/05/2024
HEREFORD, JAMESIndividualCORPORATE OFFICERsince 08/01/2017
JACOBSON, CAROLYNIndividualCORPORATE OFFICERsince 10/01/2017
WILLETT, TODDIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 10/24/2016
EBENEZER MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/30/2025
BELL, BRITTANYIndividualOPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNFsince 09/06/2021
CHEBLI, YASSERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
OLINGER, ANNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2024

CMS files one row per role, so the 23 rows in the source record cover these 16 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.

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

Follow the money — this home’s finances

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

$6.4M
Net patient revenuemost recent cost report
-75.5%
Operating marginrevenue minus expenses
$805K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 5%Medicare 32%Other / private 63%

This home reported $805K 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

$1,062per resident / day
operating cost
$32,288per month
≈ monthly operating cost
$605per 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 245634. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, 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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