Birchwood Health Care Center

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

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.

58.1% 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 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 62.0% 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 50 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 100 beds and averages 84.3 residents a day — about 84% occupied, or roughly 16 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 3.98 on weekdays — 10% thinner on weekends. RN hours go from 0.85 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

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 before2026-06-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to verify and obtain on admission a resident's need for bipap (bilevel positive airway pressure machine which delivers pressurized air through a mask over the nose or mouth to provide improvement in breathing) equipment and failed to notify the provider after prescribed breathing interventions were ineffective for 1 of 1 resident (R90) reviewed for hospitalization. This resulted in an Immediate Jeopardy situation when R90 continued to have respiratory decompensation leading to the need for transfer to the emergency room, intubation, and admission to the intensive care unit. The IJ began on 6/4/26, when R90 was hospitalized , intubated, and admitted to the intensive care unit. Administration was notified of the IJ on 6/11/26, at 3:40 p.m. The IJ was removed on 6/11/26 at 8:38 p.m., however non-compliance remained at a lower scope and severity, level 2, isolated scope, which indicated no actual harm with potential for more than minimal harm that is 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Immediate jeopardy · Jcited before2025-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to provide adequate supervision resulting in the likelihood of serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement, had exit seeking behavior, and wore a WanderGuard (security device that prevents residents at risk of wandering from a designated area). The facility's failure resulted in an immediate jeopardy when R1 exited the building without staff knowledge and was returned to the facility by a community member (CM)-A.The immediate jeopardy began on [DATE] when R1 exited the facility chapel door at 6:25 p.m. The facility was made aware of R1 missing after CM-A arrived at the facility at 6:44 p.m., with R1 who was found two blocks away. The facility director of nursing (DON), administrator, regional nurse consultant (RNC), and regional director of operations (RDO) were notified of the immediate jeopardy on [DATE] at 5:02 p.m. The facility had implemented corrective action and…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2024-02-09 · 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 Resident #51 R51's significant change Minimum Data Set (MDS) dated [DATE], indicated R51 had moderate cognitive impairment with medical diagnoses including type 2 diabetes, communication deficit or difficulties, depression, deformities of the musculoskeletal system and muscle weakness. R51's significant change MDS dated [DATE], indicated he required substantial to maximal assistance to move from lying to sitting to standing, partial to moderate assistance to roll left and was always incontinent of bowel movements. R51's significant change MDS dated [DATE], indicated R51 was at risk for developing pressure ulcers, did not have unhealed pressure ulcers, did not have other ulcers, wounds, or skin conditions of his feet, and did not reject care. The MDS further indicated skin and ulcer treatments included a pressure reducing device for the chair, bed, nutrition, or hydration interventions to manage skin problems, pressure ulcer care and applications of ointments or medications other than to feet. R51's pressure…

  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 before2024-01-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reduce the risk of accidents to prevent falls for one of one resident (R1) reviewed for falls with injuries. The facility failed to assess and add interventions following a positive Covid diagnosis with symptoms increasing the potential R1's risk for falls and did not comprehensively analyze and update the care plan with appropriate interventions following a fall that resulted in new fractures. Findings include: R1's progress noted dated 11/21/23 indicated R1 was admitted to the facility from a hospital 11/21/23 with a primary diagnosis of a spinal surgery following a fracture in his back in the 11th and 12th lumbar vertebra that resulted from a fall at home. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 11 indicating R1 had moderate cognitive impairment. R1 required moderate assist with toileting, upper body dressing and transferring. R1 required maximum assistance with…

  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 · Ecited before2026-06-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and document review the facility failed to ensure residents were given an opportunity to wash their hands prior to eating. This had the potential to affect any resident who chose to eat in the main dining room.Findings include:During an observation on 6/8/26 at 12:06 p.m., dining was in progress in the main dining room. Tables had hand wipes on the tables. Staff were not observed to offer residents an opportunity to clean their hands as they were brought in and seated at the tables.During an observation on 6/9/26 at 4:13 p.m., in the main dining room staff were bringing residents to the tables, staff were not observed offering any residents hand wipes to clean their hands. There were hand wipes on each table.During an observation on 6/9/26 at 4:25 p.m., in the main dining room staff were bringing residents into the dining room, staff were not observed offering hand wipes to residents as they brought them in.During an observation on 6/9/26 at 4:40 p.m., another resident was brought into the dining room and placed at a table, they were not offered a…

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

  Infection Control Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Dcited before2026-06-12 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a resident's call light was answered timely to prevent a bladder accident for 1 of 1 resident (R53) reviewed for bowel and bladder. Findings include:R53 was admitted on [DATE], his admission Minimum Data Set (MDS) was in progress. R53's Face Sheet dated 6/11/26, identified R53 had diagnoses which included post-polio syndrome (a progressive neurological condition that causes new or worsening muscle weakness, fatigue, and pain decades after an initial polio infection), benign prostatic hyperplasia without lower urinary tract symptoms (non-cancerous enlargement of the prostate gland that commonly occurs as men age, obstructing urine flow and causing bothersome lower urinary tract symptoms like frequent urination, weak flow, and the inability to fully empty the bladder).R53's care plan dated 6/9/26, identified R53 was at risk for falls, interventions included to have his call light accessible and within reach. R53'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.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-06-12 · 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 meet the requirements for a bed hold notification for 1 of 2 residents (R90) reviewed for hospitalization.Findings include:R90's admission Record dated 6/12/26, identified R90 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (COPD, a condition where lung tissue is damaged), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream) and hypoxia (not enough oxygen in the bloodstream), malignant neoplasm (cancer) of bronchus or lung, pulmonary hypertension, dependence on supplemental oxygen, and heart failure.R90's electronic medical record (EMR) didn't contain evidence of a bed hold offered to R90 or his spouse when he was transferred to the hospital.During an interview on 6/11/26 at 8:27 a.m., licensed practical nurse (LPN)-A stated the usual process for bed hold was when they go out ask if they want to hold the bed and provide them with bed hold policy at the time of their need…

  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 plan of correction
• Potential for harm · D2026-06-12 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services 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 ensure staff was properly educated on how to monitor a dialysis access site for 1 of 1 resident (R1) reviewed for dialysis.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, with diagnoses that included end stage renal disease (ESRD), and required dialysis.R1's care plan dated 6/9/26, indicated R1 required hemodialysis with potential for (arteriovenous) AV fistula malfunction. Instructions included to check for a thrill/bruit at the AV fistula/graft left arm access site every shift and as needed.R1's orders dated 6/11/26, indicated hemodialysis three times weekly, and instructed:Monitor hemodialysis vascular access AV fistula on left arm for signs and symptoms of infection every shift.Dialysis -Thrill/Bruit: Check Thrill (palpate) & Bruit (listen with stethoscope) every shift.Dialysis Post Run: Obtain full vital signs (VS) post dialysis run every evening shift every Tuesday,…

  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 plan of correction
• Potential for harm · D2026-06-12 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that assessments and orders were in place for self-administration of medication and bedside storage for 1 of 1 resident (R40) who was reviewed for safe self-administration and storage of medications. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 was cognitively intact with diagnoses of diabetes, chronic kidney disease, and peripheral vascular disease.R40's care plan last reviewed 3/22/26, included Focus area Med Self Administration dated 9/30/25, which indicated R40 was able to keep at besides, and self-administer Voltaren gel. The associated intervention section instructed: (9/30/25) facility to administer medications as resident is not safe to independently administer medications at this time.R40's Order Summary Report, Active Orders as of 6/11/26, included okay to have over the counter medications for nerve pain in room. The order summary lacked administration parameter orders and/or orders…

  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 plan of correction
• Potential for harm · Dcited before2026-05-06 · 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 thoroughly investigate and failed to comprehensively assess in an effort to identify risks and hazards associated with an elopement for 1 of 3 residents (R1) reviewed after R1 removed his wander alert bracelet and left the facility unsupervised by staff. In addition, the facility failed to ensure a system for all staff to identify who was at risk for elopement. Findings include:R1 quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and mental status had not acutely changed from baseline. No behaviors were indicated. R1 was independent with transfers and used a wheelchair. R1's diagnoses included hypertension, arthritis, aphasia (language disorder affecting ability to communicate effectively), CVA (stroke), Non-Alzheimer's dementia, and seizure disorder.Facility Incident Audit Report dated 4/12/26, indicated on 4/12/26, R1 had been seen around 4:00 p.m., by staff seated by the reception desk and had…

  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 before2025-12-19 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 2 of 3 (R2, R3) residents who were on enhanced barrier precautions (EBP), required personal cares and ordered treatments and staff did not maintain proper hand hygiene practices or use of gowns while performing cares and treatments.Findings include: R2's Face Sheet dated 2/16/25, indicated R2 had neuromuscular dysfunction of bladder and was a carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had a suprapubic catheter in place, and was on EBPs. R3's Face Sheet dated 10/18/25, indicated R1 had retention of urine and was a carrier or suspected carrier of MRSA. R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 had memory problems, had an indwelling catheter, had a feeding tube was dependent on staff for hygiene, and was on EBPs. Enhanced Barrier…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately assess elopement risk for 1 of 3 residents (R1) reviewed for elopement. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, diagnoses that included dementia, and had wandering behavior 1-3 days in the 7-day look back period. R1's orders dated 10/29/25, indicated check Wander Guard on right wrist every night. R1's progress notes dated 11/9/25 at 9:11 p.m., indicated R1 eloped out of the chapel doors and neighbors brought R1 back. R1's Elopement Risk assessment dated [DATE], indicated R1 was at risk for elopement with a score of 6 because R1 was able to self-propel her wheelchair, had a history of wandering, exhibited pacing or agitated behavior, was asking to go home, had a diagnosis of dementia, and was currently taking medications which may cause confusion. R1's Elopement Risk assessment dated [DATE], indicated R1 was at risk for elopement with a score of 5 because R1 was…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 2 residents (R48, R75) reviewed for call lights. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R78 had severe cognitive impairment and diagnoses of dementia. R48's care plan revised 7/2/24, indicated R48 had limited mobility related to weakness and dementia. R48 was dependent on 1-2 staff for bed mobility and required a soft touch call light in reach. An observation on 4/7/25 at 1:26 p.m., R48 was sitting up in their broda wheelchair next to the bed. The wheelchair was slightly reclined and R48 was sleeping with their arms bent laying on their torso. The chair was next to their bed. R48's soft touch call light was laying flat in the middle of the bed. An observation on 4/8/25 at 9:37 a.m., R48 was sitting in their broda wheelchair next to their bed. R48's arms were bent and laying on their torso. R48's soft touch call light was laying flat on the bed. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure feeding assistance and routine personal hygiene cares i.e., nail care, facial hair removal, was provided for 2 of 4 residents (R23, R28) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares. Findings include: R23 R23's Optional State Assessment (OSA) dated 2/19/25, indicated severe cognitive impairment, rejected cares one to three days, required extensive assist with toilet use and limited assistance with transfers. R23's annual Minimal Data Set (MDS) dated [DATE], indicated severe cognitive impairment, rejected cares one to three days, required substantial maximal assistance with toileting hygiene, showering and bathing, and personal hygiene including shaving. Further, R23 had the following diagnoses: heart failure, Alzheimer's disease, and muscle weakness. R23's care plan dated 11/26/24, indicated R23 had an ADL self-care performance deficit due to Alzheimer's disease and required…

  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

“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

$48,698 in federal fines across 3 penalties.

• $10,361 — penalty dated 2025-11-13
• $29,234 — penalty dated 2024-02-09
• $9,103 — penalty dated 2024-01-04

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 LIFESPARK — 4 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 18 rows in the source record cover these 14 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.

7 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.

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