Frazee Care Center
219 West Maple Avenue, Frazee, MN 56544 · Non profit - Corporation · 42 certified beds · (218) 334-4501 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0570)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
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 | 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 3 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 | 1.5% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.1% | 5.4% | check this* — see note marked star below the table |
| 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 | 0.0% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.8% | 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 | 2.6% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.6% | 20.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 11.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.0% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.6% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 82.7% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 66% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.1–15.8 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 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 42 beds and averages 29.2 residents a day — about 70% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 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 3.64 hrs/resident/day on weekends vs 4.60 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.28 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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.
12 citations, most serious first — scroll within the box to see all.
- Potential for harm · E2026-01-07 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the resident's trust funds reviewed for personal funds. This deficient practice had the potential to affect all 26 residents who had personal funds with the facility. Findings Include:On [DATE] at 5:00 p.m., the residents' personal funds accounts were reviewed with the assistant administrator (AA)-A. AA-A confirmed the total amount of the residents' accounts was in the amount of 24,809.91 dollars. On [DATE] at 8:16 a.m., AA-A confirmed the facility's surety bond for the residents' personal funds had expired. AA-A indicated corporate office had not renewed after the past employee responsible had left. At 8:57 a.m., during a follow up interview AA-A indicated the surety bond for the residents' personal funds accounts was important to insure the residents' funds. AA-A stated it was expectation that the surety bond would be effective. AA-A confirmed 26 residents had personal fund…
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 · E2024-11-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R28) who had repeated falls in the facility and remained at high risk for falls. In addition, the facility failed to ensure an environment that was free of accident hazards, related to hot water temperatures in 4 of 6 resident rooms (R6, R10,R13, R185) tested for safe water temperatures. This deficient practice had the ability to affect all 4 residents who used water from the water faucets. Findings include: FALLS R28's quarterly Minimum Data Set (MDS) dated [DATE], identified R28 had moderate cognitive impairment and had diagnoses which included diabetes mellitus (DM), hypertension (elevated blood pressure), and anxiety disorder. Indicated R28 required supervision with toileting and transfers. Identified R28 had one fall since the last assessment. R28's annual Care Area Assessment (CAA) dated 8/2/24, identified R28 had reduced safety awareness and required staff assistance during transfers…
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 · D2024-11-06 · 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 accurately code the oral/dental section of the Minimum Data Set (MDS) for identified dental issues for 1 of 1 residents (R13) reviewed for dental services. Findings include: R13's quarterly MDS dated [DATE], identified R13 had severe cognitive impairment, and diagnoses which included: Alzheimer's disease, anxiety, and depression. R13's significant change MDS dated [DATE], identified R13 had no natural teeth or fragments. R13's significant change Care Area Assessment (CAA), dated 2/15/24, identified R13 lacked natural teeth, did not report complications and denied need for dental check-up at that time. Identified R13 wore upper dentures and staff were to assist with cleaning and placement as needed and R13 refused lower dentures. R13's Dental/Oral Data Collection Tool dated 5/6/24, identified R13 only wore upper dentures, no teeth lower jaw, and did not wish dental visit as nothing had worked in the past and was fine. R13's Dental/Oral…
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 · D2024-11-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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 interview and document review, the facility failed to provide arrangements for follow-up care with a dentist for 1 of 1 residents (R13) reviewed for dental care. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment, and diagnoses which included: Alzheimer's disease, anxiety, and depression. R13's significant change MDS dated [DATE], identified R13 had no natural teeth or fragments. R13's significant change Care Area Assessment (CAA), dated 2/15/24, identified R13 lacked natural teeth, and did not report complications and denied need for dental check-up at that time. Identified R13 wore upper dentures and staff were to assist with cleaning and placement as needed and R13 refused lower dentures. R13's Dental/Oral Data Collection Tool dated 8/22/24, identified R13 had own teeth and upper partial. R13 was seen by ATD hygienist, likely root tips in UR and decay in UL. R13 mandible (lower jaw) was edentulous (toothless) with minimal ridge…
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 · F2024-02-13 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to submit complete and accurate data for staffing information based on payroll during Quarter 4 (July 1st-September 30th, 2023) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This deficient practice had the potential to affect all 33 residents residing in the facility. Finding include: Reviews of the Payroll-Based Journal Report (PBJ) [NAME] report 1705D Quarter 4 from 7/1/23-9/20/23, identified excessively low weekend staffing. Review of the staffing timecards identified staff, their position, and total hours worked. During the review of time cards from 7/1/23-9/20/23, revealed a shortage on 7/23/23, from 3:20 p.m. to 6:54 p.m. On 2/12/24 at 2:47 p.m., the administrator provided a change of schedule slip for 7/23/23. The change of schedule slip identified the director of nursing (DON) came in to cover the shift for registered nurse (RN)-D. The change of schedule slip was signed by DON and RN-D on 7/23/23. A review of the facility's schedule slips and timecards…
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 · E2024-02-13 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
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 confidential information was not readily available for all residents, staff, and visitors to view for 17 of 17 residents (R26, R3, R21, R28, R86, R6, R11, R22, R5, R14, R27, R8, R31, R9, R30, R20 and R10) residing on the 100's wing whose confidential information was observed to be visible on two open computer screens and a resident care sheet in a common area. Findings include: During an observation on 2/12/24 at 11:26 a.m., a resident care sheet for the 100's unit was observed on top of the medication cart with the sheet facing right side up and information visible to anyone walking by. Resident care sheet identified first and last names for R26, R3, R21, R28, R86, R6, R11, R22, R5, R14, R27, R8, R31, R9, R30, R20 and R10 , room numbers, vitals and medication notes. Registered nurse (RN)-A returned to the medication cart at 11:31 a.m., wrote on the resident care sheet, and kept the care sheet information right side up with the information still visible. RN-A opened electronic medical record (eMAR)…
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 · E2024-02-13 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 resident (R6) observed to receive an inhalation medication, and 4 of 4 residents (R4, R13, R14, R15) observed for medication administration. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 was cognitively intact, and had diagnoses which included: chronic obstructive pulmonary disease (COPD), respiratory failure and heart failure. Identified R6 received oxygen therapy. R6's comprehensive care plan dated 2/13/24, identified R6 required staff assistance with dressing, hygiene and transfers. Indicated R6 had diagnosis of COPD, with goals which included: would be free of serious complications related to respiratory disease and following doctor of medicine (MD) orders. R6's Order Summary Report signed 1/16/24, identified Fluticasone-Salmeterol (steroid) Aerosol Powder Breath Activated 250-50 microgram (MCG)/dose-1 puff inhale orally…
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 · E2024-02-13 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 document review, the facility failed to ensure insulin pens were accurately dated when opened for 2 of 3 residents (R11 and R136) who received insulin injections and insulin pens were disposed of past expiration date for 1 of 3 residents (R9) who received insulin injections. Further, the facility failed to ensure correct labeling on one refrigerated medication in 1 of 2 refrigerators reviewed for medication storage. Findings include: R11 R11's quarterly review Minimum Data Set (MDS) dated [DATE], indicated R11 had diagnoses which included diabetes mellitus (DM), malnutrition and anxiety. Indicated R11 required moderate assistance of one staff with toileting and personal hygiene. R11's signed physician's orders from [DATE] to [DATE], indicated R11 a physician's order for lantus (long acting insulin medication to control blood sugar) 10 units in the morning (AM) and 10 units at bedtime (HS) / evening (PM). R11's order audit report from [DATE], indicated R11's order was 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 · E2024-02-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure personal laundry and linen were transported in a manner that prevented risk of contamination for 3 of 3 hallways observed for linen transportation. In addition, the facility failed to ensure hand hygiene occurred during the laundry and linen distribution. Further, the facility failed to ensure infection prevention practices including hand hygiene were followed during wound cares for 1 of 1 residents (R13) observed for wound cares. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. Review of Centers for Disease Control (CDC) guidance titled Hand Hygiene in Healthcare Settings reviewed 4/28/23, identified hand hygiene protected residents receiving care and helped prevent the spread of germs. During an observation on 2/12/24 at 9:24 a.m., housekeeping aid (HA)-B…
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 · D2024-02-13 · 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 residents were assessed for the ability to self administer medications (SAM) for 1 of 3 residents (R3) reviewed for medication administration. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact. Identified R3 had diagnoses which included heart failure, anxiety and depression. Indicated R3 required moderate assistance of one staff with toileting and personal hygiene. Review of R3's electronic health record (EHR) revealed a SAM assessment had not been completed and R3 did not have an order for self administration of medications. R3's Physician's Telephone Orders dated 2/5/24, and signed 2/12/24, directed staff to administer DuoNeb (medication used to relax the muscles in the airways and increase air flow to the lungs) four times daily (QID) for seven days then as needed (PRN) for wheezing and shortness of breath (SOB). R3's Medication Administration Record (MAR) dated…
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 · D2024-02-01 · 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 interview and document review, the facility failed to have a system in place to assure protocols for periodic evaluation (at least weekly), which include wound measurements and other wound characteristics, were completed and documented for 1 of 1 resident (R2) reviewed for pressure injury. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], indicated R2 was admitted to the facility on [DATE], and diagnoses included anemia, end stage renal disease and had severely impaired cognition. Significant change MDS also indicated R2 did not exhibit any behaviors, was determined to be at risk of developing pressure ulcers and had two stage 2 pressure ulcers and one unstageable pressure ulcer. R2's care plan dated 1/31/24, identified R2 had actual complications with impaired skin integrity with interventions that included encouraging a high protein diet, staff to complete daily dressing changes and wound monitoring, provide education to R2 and family regarding offloading, waffle cushion…
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 · C2024-02-13 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 three years of survey results were readily accessible to residents and visitors. This deficient practice had the potential to affect all 33 residents currently residing in the facility. Findings include: During an observation on 2/12/24 at 10:00 a.m., a survey results book was located affixed to the wall in the main lobby of the facility, by the front door. The survey results book had survey results from the 2019, 2020, 2021, 2022, and 2023 recertification surveys. The survey results book lacked the deficiency from the 8/8/23, complaint investigation. During an interview on 2/12/24 at 10:23 a.m., assistant administrator (AA)-1 verified the 8/8/23, deficiency from the complaint investigation was not located in the survey book. During an interview on 2/12/24 at 10:31 a.m., administrator stated he was unaware the deficiencies from complaint investigations needed to be included in the survey results book for residents to review when requested. Review of a facility policy titled Examination of survey…
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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HEALTH DIMENSIONS GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 5 of 5 | 3.7 | +1.3 vs chain |
The other 9 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LEGACY SENIOR SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/23/2007 |
| FIRST RESOURCE BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 08/01/2007 |
| HDG REAL ESTATE, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 01/07/2020 |
| BECK, ROBERT | Individual | CORPORATE DIRECTOR | — | since 09/08/2013 |
| GREEN, ROGER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/01/2007 |
| JENSEN, JOEL | Individual | CORPORATE DIRECTOR | — | since 06/07/2013 |
| LUNDE, ERIC | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 08/01/2007 |
| PAITICH, NADINE | Individual | CORPORATE DIRECTOR | — | since 05/19/2022 |
| HEALTH DIMENSIONS CONSULTING INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2007 |
| ANDERSON, MOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| BIRKY, ALEXIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/20/2013 |
| KREJCI, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2020 |
| SCHMIDT, KELLY | Individual | ADP OF THE SNF | — | since 02/07/2019 |
CMS files one row per role, so the 20 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
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 245299. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.