The Waterview Woods LLC

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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

Quality measures — how residents actually fare

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.

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.

64.4% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.0% 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 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% 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.

Staffing

How full it usually is: this home is certified for 65 beds and averages 50.8 residents a day — about 78% occupied, or roughly 14 beds typically open. It usually has some room. 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 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.59 hrs/resident/day on weekends vs 3.08 on weekdays — 16% thinner on weekends. RN hours go from 0.36 to 0.02 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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.

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

• Immediate jeopardy · Jcited before2024-12-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for 1 or 1 resident (R1) reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling (a sling which does not cover the buttocks) of unknown size, fell out of the sling during the transfer, and sustained a laceration to the back of head. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance. The IJ began on 12/22/24 at 8:10 p.m., when R1 was transferred with a ceiling lift using a reported toileting sling of unknown size. R1 slipped out of the sling during the transfer which resulted in R1's head hitting the ground and sustaining a laceration to the back of the head. The administrator and director of nursing (DON) were informed of…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-10-24 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 resident with an allergy to shellfish was not served shellfish for 1 of 1 resident (R209) reviewed for food allergies. The resident was fed a dinner containing shellfish, had an allergic reaction, and was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency is issued as past non-compliance. The IJ began on 10/13/24 at 5:15 p.m. when R209 was served, and consumed, shrimp. R209 complained of numbness of the tongue and lips and was sent to the ED for treatment of allergic reaction. The administrator and director of nursing (DON) were informed of the IJ on 10/24/24 at 11:13 a.m. The facility implemented corrective action on 10/14/24, prior to the start of the survey, therefore, was past non-compliance. Findings include: R209's undated face sheet identified he…

  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 · Past Non-Compliance
• Actual harm · Gcited before2024-02-08 · 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 notify the provider, monitor, determine root cause and revise interventions to address pressure ulcers for 1 of 2 residents (R21) reviewed who was at risk for pressure ulcer development/deterioration. The facility's failure resulted in harm when R21 developed 2 pressure ulcers, one that deteriated to a stage 3 and another to a stage 4. In addition, R1 had documented redness and skin breakdown to the buttocks area and a right heel wound that both deteriorated to unstageable pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) definition of a stage 3 pressure ulcer included: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-08 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to promptly obtain opioid medication and failed to notify the physican to prevent opioid withdrawal for 1 or 1 residents (R13) reviewed for pain management. This practice resulted in a significant medication error and actual harm when R13 did not receive opioid medication for 7 consecutive days resulting in R13 being sent to the emergency room to receive care for acute opioid withdrawal. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact and reported almost constant pain, which limited ability to sleep and complete day to day activities. MDS diagnoses included neurofibromatosis type 2 (growth of noncancerous tumors in the nervous system), long term (current) use of opiate analgesic, and paraplegia. R13's elder care visit summary dated 1/2/2024, identified R13 was prescribed 4 milligrams (MG) of oral hydromorphone (opioid medication) every 4 hours as needed for pain. R13 was not…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-11-20 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. This had the potential to affect all 55 residents who resided at the facility.Findings include:Review of the facility Staffing Schedules dated 4/1/25 through 6/30/25, revealed there was no RN coverage for the following dates: 4/5/25, 4/6/25, 4/13/25, 4/20/25, 5/3/25, 5/4/25, 5/10/25, 5/11/25, 5/17/25, 5/24/25, 5/31/25, 6/1/25, 6/7/25, 6/8/25, 6/14/25, 6/15/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25.Review of the facility Condensed Employee Time Detail for the following dates identified a lack of RN coverage: 4/5/25, 4/6/25, 4/13/25, 4/20/25, 5/3/25, 5/4/25, 5/10/25, 5/11/25, 5/17/25, 5/24/25, 5/31/25, 6/1/25, 6/7/25, 6/8/25, 6/14/25, 6/15/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25.During an interview on 11/19/25 at 3:30 p.m., licensed practical nurse (LPN)-B stated she normally worked night shifts. There was usually one licensed staff with two nursing assistants in the building. There may be another nursing assistant that would float between…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · 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 follow a self-administration of medication (SAM) form which indicated the resident should not self-administer medications. The facility also failed to have a provider order to self-administer medications and to keep medications at bedside. Lastly the facility failed to appropriately assess a resident with memory and decision-making concerns that was allowed to self-administer medications. This effected 2 of 3 (R25, R29) residents reviewed for self-administration of medications.Findings include R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had mild cognitive impairment. Diagnoses included atrial fibrillation and sepsis. R25's care plan dated 10/21/24, identified R25 chose to self-administer oral medications left at bedside after setup by nursing. The goal was for the resident to safely administer medications set up by nursing and left at bedside per provider orders. Interventions included nursing to ensure medications…

  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 · D2025-11-20 · 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 document review, the facility failed to provide a bed hold notice for 1 of 1 resident (R2) reviewed for hospitalization. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had a diagnosis of stroke with left sided hemiplegia (paralysis that affects one side of the body). R2's Face Sheet dated 11/20/25, identified R2 was admitted on [DATE] and discharged to an acute care hospital on [DATE]. R2's progress notes dated 11/9/25, identified R2 was transferred to a local hospital by Emergency Medical Services (EMS)(ambulance). The medical record lacked documentation a bed hold was given or discussed. R2's progress note dated 11/10/25, identified R2 called the facility and stated they were being transferred to a larger acute care hospital. The medical record lacked documentation a bed hold was give or discussed. During an interview on 11/20/25 at 12:12 p.m., the clinical manager (CM) stated when a resident was transferred to the 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 2 of 2 residents (R7, R63) reviewed for behaviors and transmission-based precautions (TBP). Findings include: R7: R7's annual Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses which included dementia and post-traumatic stress disorder. In addition, R7's MDS identified he was severely cognitively impaired and had verbal behaviors that were directed towards others. R7's care plan initiated on admission 8/25/25, did not address behaviors until 11/18/25. R7's nursing notes identified the following: 8/17/25 at 1:39 p.m., Resident came out to nurse's desk asking CNA (certified nursing assistant) for pain pill. CNA stated she will let nurse know. Resident stated you are fat you are too f fat to work here. CNA stated you can go wait in your room for the nurse and I will let her know you want a pain pill, have a great nite *. He then stated f* you and went back 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 · Dcited before2025-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition.Based on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition.Findings include:R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 had diagnoses which included moderate difficulty with hearing and had hearing aids, mild cognitive function, depression, and anxiety. In addition, R35's MDS identified he was rarely/never understood and had memory problems.R35'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · 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 observation, interview and document review, the facility failed to provide timely assistance with repositioning to prevent the worsening or development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had diagnoses which included diabetes, morbid obesity, heart failure (a chronic condition where the heart can't pump enough oxygen rich blood to meet the body's needs), and pressure ulcer. In addition, R1's MDS identified her as cognitively intact and as having a pressure ulcer.R1's electronic medical record banner identified the following special instructions; elevation of lower extremities 4x (times) a day for 15 min (minutes) needs to be done every day.R1's care plan dated 12/20/24, identified R1 had an alteration in skin integrity to top of left foot, left heel, and buttock. Interventions included turn and reposition or reminders to offload every two to three hours and as needed.R1's Order Summary…

  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 before2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement interventions to prevent falls for 1 of 3 (R44) residents reviewed for falls.Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE] indicated R44 had moderative cognitive impairment. Diagnoses included alcohol dependence and delirium. R44's care plan dated 8/14/24, identified R44 was a fall risk related to dementia and safety. Interventions included wheelchair to be kept at bedside with brakes locked and auto-locking breaks on WC. Gripper socks were to be on when out of bed. On 11/17/2025 at 4:14 p.m., R44 was observed to self-transfer from the bed to the wheelchair. The wheelchair locks were not locked and R44 was wearing regular socks with his shoes lying on the floor. R44 was unsteady during transfer, leaned forward to grab the wheelchair and the wheelchair rolled backwards. R44 was able to grab both wheelchair arms and sit down before the wheelchair rolled away from R44. On 11/19/25 at 10:26 a.m., nurse…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to monitor pain, provide non-pharmacological pain management, and consistently administer as needed pain medication to minimize pain for 1 of 1 resident (R61) who had pain. R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 was cognitively aware and had diagnoses that included chronic obstructive pulmonary disease (COPD) (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. Common symptoms are chronic cough, mucus, and shortness of breath, which worsen over time and are often exacerbated by smoking or exposure to irritants.), emphysema (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. Common symptoms are chronic cough, mucus, and shortness of breath, which worsen over time and are often exacerbated by smoking or exposure to irritants.),…

  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 · D2025-11-20 · 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 make sure all medications in a resident room had active orders and were not expired. This affected 1 of 1 (R29) resident reviewed for medication storage.Findings include R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact. Diagnoses included heart failure, depression and anxiety. R29's care plan lacked documentation related to creams at bedside and labeling requirements. R29's active order summary report dated [DATE], indicated an order for Diclofenac Sodium external gel 1% and Clotrimazole external cream 1%. The active order summary report lacked orders for any other medicated creams or lotions. On [DATE] at 4:18 p.m., a white basket with several tubes of medicated creams was observed in R29's room on the counter next to the bathroom and R29's other care items. On [DATE] at 2:40 p.m., a white basked with several tubes of medicated creams was again observed in R29's room on the counter next to 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure 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 consultant pharmacist recommendations were addressed for 1 of 5 residents (R1) reviewed for unnecessary medications.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had diagnoses which included diabetes, morbid obesity, heart failure (a chronic condition where the heart can't pump enough oxygen rich blood to meet the body's needs), and pressure ulcer. In addition, R1's MDS identified her as cognitively intact and as receiving insulin injections seven days of the week and receiving anti-psychotic medication.R1's care plan dated 12/20/24, identified a potential for psychotropic adverse drug reactions related to daily use of psychotropic medication. Interventions included monitoring for adverse drug reactions, medication review by pharmacist and medical provider, and updating the medical provider of efficiency of medications. R1's Order Summary Report identified the following order: 10/24/24, quetiapine 25…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$55,269 in federal fines across 3 penalties.

• $15,642 — penalty dated 2024-12-31
• $15,642 — penalty dated 2024-10-24
• $23,985 — penalty dated 2024-02-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MONARCH HEALTHCARE MANAGEMENT — 45 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 →

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

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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 $972K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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