Lakeview Methodist Health Care Center
610 Summit Drive, Fairmont, MN 56031 · Non profit - Corporation · 72 certified beds · (507) 235-6606 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.4% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.5% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.9% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.9% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.8% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.5% | 20.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 12.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.2% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.2% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.2% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 6.5% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.8% | 14.8% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.8% 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 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.8%CMS range 55.8–74.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.3–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 62.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 91.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.2–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 72 beds and averages 67.1 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.15 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.11 hrs/resident/day on weekends vs 5.04 on weekdays — 19% thinner on weekends. RN hours go from 0.95 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2025-11-19 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews the facility failed to ensure grievance forms were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously. This had the potential to affect all 66 residents in the facility. Findings include:On 11/18/25 at 10:30 a.m., during the resident council meeting, residents R7, R25, R26, R42, R43, and R62 stated they were not aware of any method to submit concerns anonymously. The residents also reported that grievance forms were not readily available and could only be obtained by asking staff. R25 further stated grievance forms had previously been available in multiple locations throughout the facility but were no longer accessible to residents without requesting them from staff.On 11/18/25 at 12:12 p.m., during a facility tour, social services (SS)-A confirmed there were no grievance forms in the designated areas accessible to all residents, which were expected at the end of each wing on first and second floor. SS-A stated grievance forms had previously been available at the end…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a care plan was implemented to ensure activity preferences were identified and implemented for 1 of 2 residents (R31) reviewed for activities.R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility 10/16/25, had moderately impaired cognition, required partial to moderate assistance with transfers, and substantial/maximal assistance with shower/bathe and dressing, and required supervision with eating and oral hygiene. R1 identified it was somewhat important to do her favorite activities, keep up with the news, participate in religious services, go outside to get fresh air, have reading material, listen to music, and do things with groups of people. R1's diagnoses included anemia, heart failure pneumonia, macular degeneration (chronic eye condition that affects retina leading to significant visual impairment) and depression. R1's baseline/comprehensive care plan dated 11/3/25, did not include…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure individualized activities were care planned and provided for 1 of 2 residents (R1) reviewed for activities. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was admitted to the facility 10/16/25, had moderately impaired cognition, required partial to moderate assistance with transfers, and substantial/maximal assistance with shower/bathe and dressing, and required supervision with eating and oral hygiene. R1 identified it was somewhat important to do her favorite activities, keep up with the news, participate in religious services, go outside to get fresh air, have reading material, listen to music, and do things with groups of people. R1's diagnoses included anemia, heart failure pneumonia, macular degeneration (chronic eye condition that affects retina leading to significant visual impairment) and depression. R1's baseline/comprehensive care plan dated 11/3/25, did not include R4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide routine passive range of motion (PROM) on a consistent basis to improve strength, mobility and improve circulation for 1 of 1 resident (R32) reviewed for ROM. In addition, the facility failed to identify and develop interventions to reduce the risk of potential complications of a hand contracture.Findings include:R32's facesheet printed on 11/19/25, included diagnoses of traumatic brain injury, Parkinson's disease, and dementia.R32's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no speech, rarely/never understood, sometimes responded to simple, direct communication only. Dependent upon staff for all activities of living (ADL). R32's physician orders dated 4/13/21, indicated restorative nursing measures such as PROM, ambulation, transfers, ADL may be implemented following an assessment by a licensed nurse.R32's care plan, undated and printed on 11/19/25, indicated R32 had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure basic infection control practices were followed when the tubing of a urinary drainage bag for 1 of 1 resident (R8), was observed laying on the floor of the shower. The deficient practice had the potential to cause infection.Findings include:R8's face sheet printed on 11/19/25, included diagnoses of stroke, obstructive and reflux uropathy (blockage that prevents urine from flowing, causing it to back up), bacteremia (bacteria in blood) and history of urinary tract infections.R8's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, usually understood and could understand. R8 had a urinary catheter. R8 walked with supervision or touch assistance or used a wheelchair for mobility.R8's physician orders dated 2/10/25, included indwelling catheter. R8's undated care plan, printed on 11/19/25, indicated R8 had an indwelling catheter related to retention. Catheter care per facility policy. During an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure documentation for 2 of 5 residents (R65 and R5) who refused influenza vaccine included education covering benefit and risk of the vaccine, and name and date of resident or representative who refused the vaccine Findings include:R65's face sheet printed on 11/19/25, indicated R65 was admitted on [DATE], and diagnosis included Parkinson's disease.R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R65 used a walker or wheelchair for mobility. R65's standing orders dated 6/11/25, indicated may have annual Influenza vaccine unless contraindicated. During record review for immunizations, the immunization section of the electronic medical record (EMR) indicated the influenza vaccine had been refused, however no additional documentation indicated when it had been offered, if education had been provided including benefit and risk, if allergic or contraindicated.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0887 — isolatedEducate 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 documentation for 1 of 5 residents (R65) who refused Covid-19 vaccine included education covering benefits and risks of the vaccine, and name and date of resident or representative who refused the vaccine. Findings include:R65's face sheet printed on 11/19/25, indicated R65 was admitted on [DATE], and diagnosis included Parkinson's disease.R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand, used a walker or wheelchair for mobility. R65's physician orders did not include Covid-19 immunization. During record review for immunizations, the immunization section of the electronic medical record (EMR) indicated the Covid-19 vaccine had been refused, however no additional documentation included when it had been offered, if education had been provided including benefit and risk, if allergic or contraindicated. During interview on 11/19/2025 at 8:00 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to ensure beverageware was completely dry before storing, in order to prevent bacterial growth. This had the potential to affect all 29 residents who resided on second floor. Findings include: During an observation and interview on 10/22/24 at 1:51 p.m., observed multiple beverageware stacked on trays, sitting on an open cart located between kitchenettes on second floor. Observed stacked clear plastic cups, light blue plastic cups, and thermal coffee cups. Condensation was visible in the stacked light blue cups. Dietary aide (DA)-A was asked to pick up and separate a stack of blue cups and looking in the cups, verified moisture was present. In addition, DA-A picked up several thermal coffee cups and verified there was moisture inside the cups as well. DA-A explained when she removed beverageware from the dishwasher, she placed them on the counter on top of a piece of rubber shelf-liner to air dry. DA-A acknowledged moisture remaining in cups could lead to bacterial growth. During an interview on 10/22/24 at 2:05 p.m., dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R264) reviewed who was observed to have medications at the bedside, had been appropriately assessed and deemed appropriate to self-administer medications. Findings include: R264's admission Record printed 10/24/24, identified diagnoses including bloodstream infection, muscle spasm of the back, and lack of blood flow to the muscle. R264's entry tracking record Minimum Data Set (MDS) assessment dated [DATE], identified admission date of 10/14/24, and admission from short-term general hospital stay. R264's care plan printed 10/24/24, identified R264 required extensive staff assistance for grooming, transfers, bed mobility, and dressing. Care plan further indicated R264 was at risk for ineffective coping related to health status with interventions of re-orientation, allow time to process, move slowly with cares and give simple explanations. R264's Order Summary Report printed 10/24/24, identified an order 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.
- Potential for harm · D2024-10-24 · tag F0641 — isolatedEnsure each resident receives an accurate 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 observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 2 residents (R42) reviewed for elopement devices and 1 of 1 resident (R62) reviewed for hospitalization. Findings include: R42's Face Sheet, printed 10/24/24, included diagnoses of dementia and senile degeneration of the brain. R42's quarterly Minimum Data Set (MDS) dated [DATE], section P, P0200 under alarms, did not include a wander/elopement alarm. During observation and interview on 10/23/24 at 10:58 a.m., R42 was in her wheelchair propelling herself with her feet, and approached room [ROOM NUMBER] (empty room) and opened the closed door. R42 had a wanderguard (bracelet worn to prevent elopement) bracelet on her left lower leg. R42 closed the resident room door without entering and wheeled self towards the unit exit doors, with side of door open to hallway and other door closed. R42 made it to through the door when a staff member…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-10-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a care plan was revised to address pressure ulcer risk and preventative measures for 1 of 2 residents (R31) reviewed for pressure ulcers (PU). Findings include: R31's face sheet printed 10/23/24, included diagnosis of Parkinson's disease (progressive movement disorder), lymphedema (swelling of the leg or arm), and body mass index 36.0 - 36.9 (normal is 25-30). R31's quarterly Minimum Data Set (MDS) dated [DATE], identified one stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) not present on admission. Cushion on chair, air mattress on bed. R31's physician orders dated 6/28/24 included apply rolled towel to left lower leg for left lateral malleolus (bony prominence on each side of the human ankle) pressure reduction every shift for left lateral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess skin and/or consistently implement interventions to prevent the development of new pressure ulcers for 2 of 2 residents (R31, R48) who were reviewed for pressure ulcers. Findings include: R31's Face Sheet printed 10/23/24, included diagnoses of Parkinson's disease (progressive movement disorder), lymphedema (swelling of the leg or arm), and body mass index 36.0 - 36.9 (normal is 25-30). R31's quarterly minimum data set (MDS) dated [DATE], identified R31 was cognition was intact, needed substantial to moderate assistance for all activities of daily living except was able to eat independently. Further, the MDS indicated R31 was at risk for pressure ulcer (PU) development, currently had a stage III pressure ulcer ( (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R314) who was observed using an electric heating pad, was free of potential injury. Findings include: R314's facesheet printed on 10/22/2024, included diagnoses of rheumatoid arthritis, disc degeneration, and age-related osteoporosis. R314's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R314 was cognitively intact and was independent in most activities of daily living (ADL's). R314's MD orders included Aqua-K pad 20 minutes TID (three times a day) as needed for pain relief every 8 hours. R314's care plan dated 1/19/24, indicated to offer warm blanket, massage, cold Pak, repositioning, rest/relaxation. warm bath/ whirlpool, and/ or diversional activities for pain. R314 treatment administration record (TAR) indicted the Aqua-K pad had not been used in September or October 2024. During an observation on 10/22/24 at 10:30 a.m., a heating pad was observed laying over the arm of a recliner 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.
- Potential for harm · Dcited before2024-10-24 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 2 of 5 resident (R36, R58) were administered the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, diagnoses included: stroke, hypertension (high blood pressure), and Parkinson's Disease (brain disorder that affects movement and other systems of the body), and was not up to date on her pneumococcal vaccinations R36's Immunization Report dated 10/23/24, indicated on 5/13/24, R36 consented to the Pneumovax (pneumococcal) vaccine. R36's record review failed to indicate the pneumococcal vaccine was administered. R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, had diagnoses of anemia, coronary artery disease, hypertension, hip fracture, dementia, and obstructive sleep, and was not up to date on her pneumococcal vaccination. R36's Immunization Report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow phsycician's orders per the standard of practice related to urostomy bag changes for 1 of 1 resident (R1) who had bilateral urostomies. Findings include: R1's after visit summary (AVS) from hospital dated 8/26/24, indicated R1 was admitted on [DATE], with history of bladder cancer with cystectomy (removal of bladder) and bilateral urostomies (tube from kidney to skin for drainage or urine). The AVS directed staff to change the drainage pouches twice weekly with the following: [NAME] wafer #14904, [NAME] 7805 moldable barrier stretched and placed around the opening of the adhesive side of the wafer, [NAME] 18402 urinary pouch. R1's admission Minimum Dasta Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment. R1's diagnoses included cancer, renal insufficiency, failure or end stage renal disease, diabetes, and malnutrition. R1 had a urostomy and required partial to substantial assist with activities of daily living…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to identify and date facility-made frozen soups stored in 4 of 4 kitchenettes, and failed to ensure dishes in the kitchen were stored dry. This had the potential to affect all 61 residents who resided in the facility. Finding include: During an observation on 12/6/23 at 9:58 a.m., observed full-sized refrigerators in each kitchenette on each of four resident units. Observed in each freezer were multiple half-pint, plastic containers of an unknown food. The containers had not been labeled with contents, nor dated. During an observation and interview on 12/6/23 at 10:40 a.m., in the kitchen, dietary manager (DM)-A picked up clean metal steam table pans that had been stacked one on top of another on a wire rack. DM-A picked up two pans that were wet inside and one pan that had dried food on it. DM-A gave all three pans to the dishmachine worker to redo and asked another dietary worker to check all pans to ensure they were clean and dry. During the same interview, DM-A was informed of frozen containers of food on the units 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.
- Potential for harm · Fcited before2023-12-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19 when during a Covid-19 outbreak, failed to ensure appropriate use of personal protective equipment (PPE) when staff were observed not an wearing N-95 mask in the room of 1 of 1 resident (R51) in transmission based precautions (TBP) for Covid-19; failed to doff (remove) PPE per guidelines with staff were observed removing all PPE including N-95 masks prior to exiting the room of residents in TBP for Covid-19 for 4 of 4 residents (R51, R53, R29, R30); failed to ensure precautions posted on resident room doors (R51, R34, R29, R53, R211, R43, R22, R30, R159 and R160) were consistent and followed CDC recommendations; failed to ensure all staff were fit-tested for use of N-95 masks or respirator use for 3 of 3 employees (HSK-A, LPN-C, NA-C); failed to ensure masking occurred in public areas of the facility;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 1 residents (R17) who required assistance with dining. Findings include: R17's admission Record printed 12/6/23, indicated R17's diagnoses included traumatic brain injury, Parkinson (nervous system disorder progressive movement disorder that causes tremor in one hand, stillness or slowing of movement), and dementia. R17's quarterly Minimum Data Set (MDS) assessment, dated 10/4/23, identified R17 rarely to never is understood, occasionally understands, does not speak, and is totally dependent with all care including assistance with feeding from assistance of 1 person. R17's care plan printed 12/6/23, identified an activities of daily living (ADL) self care performance deficit and requires assistance by 1 staff to eat. During an observation on 12/4/23 at 12:39 p.m., R17 was sitting in his Broda chair (positioning wheelchair) at a table in the dining room with his meal in front of him. At 1:09 p.m., nursing assistant (NA)-C sat down to assist R17 with the meal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notify a provider of a significant physical change for 1 of 1 resident (R10) reviewed for notification of change. Findings include: R10's face sheet printed on 12/6/23, included a diagnosis of congestive heart failure, and new diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis on one side of the body) following a stroke, affecting right dominate side with aphasia (loss of ability to understand or express speech) dated 12/1/23. R10's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact, had clear speech, was understood, and could understand. R10 had been independent with most all activities of daily living (ADL's). R10's care plan dated 12/4/23, indicated R10 had a stroke affecting her right dominate side and expressive aphasia, and would show improvement to maximum potential with mobility and cognition. R10's physician orders dated 11/4/21, included a standing order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide routine removal of facial hair for 1 of 1 resident (R17) and bathing for 1 of 1 (R30) resident reviewed for activities of daily living (ADLs) who were dependent on staff for cares. Findings include: R17's admission Record printed 12/6/23, indicated R17's diagnoses included traumatic brain injury, Parkinson (nervous system disorder progressive movement disorder that causes tremor in one hand, stillness or slowing of movement), and dementia. R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 does not speak, is rarely understood and occasionally understands. R17 was totally dependent with all activities of daily living cares (ADL's) and had no behaviors including care refusal. R17's care plan printed on 12/6/23, indicated R17 had an ADL self-care performance deficit R/T [related to] dementia, Parkinson's, limited mobility and traumatic brain injury. R17 requires total assist with all ADL's and does not use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 interview and document review, the facility failed to make an appointment for 1 of 1 resident (R44) reviewed for vision. Findings include: R44's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R44 had moderately impaired cognition, was dependent on staff for toileting, personal hygiene, required partial/moderate assistance with upper body dressing, adequate vision, and no corrective lenses, diagnoses included: dry eye syndrome and cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain). Care plan printed 12/6/23, indicated R44 has impaired visual function r/t (related to) hx (history) of CVA (cerebrovascular accident) and intervention included arrange consultation with eye care practitioner as required. Progress note dated 9/6/23 at 1:10 p.m., registered nurse (RN)-E indicated R44 was complaining about double vision and states that We've known about it for two years, writer explained that this was the first I had heard of it, but we could try to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure weekly comprehensive skin assessments were completed for 1 of 3 residents (R27) reviewed for pressure ulcers Findings include: R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 had severe cognitive impairment, dependent on staff with toileting, showers, dressing, personal hygiene, at risk for pressure ulcers, had one unhealed Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.), and one unstageable - deep tissue injury; skin and ulcer/injury treatments included pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care applications of ointments/medications; diagnoses include stroke, stage II pressure ulcer of the left heel, pressure induced deep tissue damage of right heel and weight loss.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to accurately assess and monitor ongoing safe smoking practices for 1 of 1 resident (R23) reviewed for smoking. Findings include: R23's admission Record printed 12/6/23, included diagnoses of anxiety disorder, heart failure, end stage renal (kidney) failure dependent on renal dialysis, malignant neoplasm of transverse colon (cancer that begins in the last part of large intestine) and acquired absence of right leg above the knee. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had moderate impairment of cognition. The MDS also indicated R23 required extensive assistance of one for activities of daily living (ADL's), and had lower extremity impairment on one side. R23's MDS question regarding tobacco use was not answered yes or no. Oxygen use was blank. R23's smoking assessment dated [DATE], indicated R23 utilizes tobacco with no concerns identified with smoking safety evaluation except resident is to follow the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 1 resident (R7) reviewed for weight loss. Findings include: R7's face sheet printed on 12/6/23, included diagnoses of fracture of the acetabulum dome (a break in the hip socket) on left hip, Parkinson's disease and dementia. R7's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had severely impaired cognition, clear speech, could understand and be understood. R7 required extensive assistance from one staff for all activities of daily living (ADL's) except eating in which he required supervision. R7's care plan printed on 12/6/23, indicated R7 had a nutritional problem related to chronic diagnoses, his dentures were loose due to weight loss, and intake was variable. Interventions included use of a lip plate, 120 ml (milliliters) of supplement of choice once daily, to monitor intake and record every meal. R7's physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure oxygen tubing was changed and dated timely, and failed to create a comprehensive plan of care for oxygen therapy for 1 of 2 residents (R50) reviewed for respiratory care. Finding include: R50's admission Minimum Data Set (MDS) dated [DATE], indicated R50 was cognitively intact, required set up assistance with bed mobility, transfer, eating; required one person physical assist with dressing, toilet use, and personal hygiene, utilized a walker and wheelchair, diagnoses included respiratory failure and indicated R50 used oxygen therapy. R50's care plan dated 8/15/23, indicated R50 had altered cardiovascular/respiratory status and intervention included monitor/document/report as needed any changes in lung sounds on auscultation (example crackles), edema and changes in weight, respiratory monitoring per facility protocol and did not address oxygen use. R50's record review failed to indicate R50's oxygen tubing or oxygen humidification…
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.
- No harm found · C2024-10-24 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents (R3, R12, R19, R24, R32, R41, R49) who voiced concerns with mail delivery during resident council. This deficient practice had the potential to affect all 61 residents residing in the facility. Findings include: Resident Council was held on 10/23/24 at 11:00 a.m., R3, R12, R19, R24, R32, R41, R49 attended. R3, R12, R19, R24, R32, R41, R49 stated they did not receive mail on Saturdays and received the mail on Monday through Friday. R12 stated the mail was delivered to the post office and not to the facility. On 10/23/24 at 11:18 a.m., activity director (AD)-A confirmed resident mail was not delivered on Saturdays, and further stated activity staff delivered the mail to residents Monday through Friday. AD-A stated on Saturdays activity staff were not at the facility after 1:00 p.m., and the post office delivered the mail to the facility after 1:00 p.m., so therefore mail was not delivered to the residents. On 10/23/24 at 11:21 a.m., staffing coordinator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GREEN, JEFFREY | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| BARNES, DEBORAH | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/08/2025 |
| ADAMS, JEFF | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| BACHENBERG, TIMOTHY | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| EDMUNDSON, BRANDON | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| HAUGEN, CHARLES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 10/01/2023 |
| LUND, JOHN | Individual | CORPORATE DIRECTOR | since 04/24/2013 |
| MUSSER, BRADLEY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/01/2014 |
| NORDSTROM, NANCY | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| SUBBERT, JASON | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| TUMBLESON, MELISSA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 10/01/2023 |
CMS files one row per role, so the 21 rows in the source record cover these 11 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.
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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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