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Maple Lawn Senior Care

400 Seventh Street NE, Fulda, MN 56131 · Non profit - Corporation · 46 certified beds · (507) 425-2571 Medicare & Medicaid certified

Call the home — (507) 425-2571 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 2024Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
201 N St Paul Ave · (507) 425-2933 · Call to confirm hours
Pharmacy
115 N St Paul Ave · (507) 425-3166 · Call to confirm hours
Grocery
119 N Saint Paul Ave · (507) 425-2168 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
400 N Maryland Ave · (507) 425-2258

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 2 of 5
Long-stay residentspeople who live here 2 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.3%18.2%15.4%worse
Long-stay residents who lose too much weight4.3%4.1%5.4%better
Long-stay residents with a catheter left in their bladder1.4%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.5%2.6%2.0%worse
Long-stay residents with depressive symptoms1.7%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.6%4.0%3.3%worse
Long-stay residents whose ability to walk worsened19.6%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.5%12.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers0.9%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control29.1%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.4%17.1%17.1%typical

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.

not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot 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.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 staynot 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 worsenednot 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 hospitalizationnot 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 SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.06
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.83
Aide hours/ resident / day
4.57
Total nurse hours/ resident / day
0.52
RN hoursweekends
64.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 46 beds and averages 34.2 residents a day — about 74% occupied, or roughly 12 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 4.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 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 3.93 hrs/resident/day on weekends vs 4.83 on weekdays — 19% thinner on weekends. RN hours go from 1.28 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2026-02-26)
3
at the previous standard inspection (2024-12-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · F2026-02-26 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days a week for 1 of 92 days reviewed. This had the potential to affect all 33 residents. Findings include: Review of the facilities November 2025, December 2025, and January 2026 schedules identified on 11/29/25 the facility had no registered nurse on duty. Interview on 2/26/26 at 8:23 a.m., with the director of nursing identified she was responsible for the licensed nurse schedule. She reported she was on duty Monday through Friday 8 consecutive hours and if she needed to leave early, she would ensure there was another RN to cover the 8-hour requirement. On the weekends she ensured there was a RN scheduled 8 consecutive hours and if the facility did not have an RN to work over the weekend, she or another facility RN would come in and cover the RN 8 consecutive hours requirement. She confirmed that there had been no RN coverage on 11/29/25. Review of undated, RN Coverage policy identified the facility would ensure the services of 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · F2026-02-26 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 designate a qualified person to serve as the director of food service to oversee the dietary department. This had the potential to affect all 33 residents.Findings include: Interview on 2/23/26 at 12:00 p.m., with the facility designated dietary manager (DM) revealed she was not certified. She had been enrolled but dropped the class this past December because of personal life issues that made it difficult for her to continue. She had not submitted any of her course work that was required to complete the class and currently was not enrolled in any program. Interview on 2/24/26 at 11:22 a.m., with the registered dietician identified she was the DM's preceptor and was available to her to help her with any questions and review her coursework, however, her understanding was the DM was out on medical leave and was unable to complete the course work, therefore she had dropped the class. Interview on 2/26/26 at 8:31 a.m., with the administrator identified she would have expected the DM to be certified for 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 the resident had a care conference to be able to participate in the planning process and development of interventions of their care for 1 of 1 sampled resident (R7) who had been at the facility for 3 months with no care conference scheduled. Findings include: R7's 12/01/25, accepted admission Minimum Data Set (MDS) assessment identified that R7 had admitted to the facility in the middle of November 2025. R7 cognition was intact. She used a walker or a wheelchair for mobility and required partial assistance with some activities of daily living (ADL's). She had diagnoses of arthritis, thyroid disorder, diabetes, renal disease, and hypertension. R7's plan was to remain living in the facility. Additionally, a 2/20/26, accepted quarterly MDS assessment was completed identifying again R7's cognition was intact. Interview on 2/23/26 at 2:33 p.m., with R7 identified, she had not been invited to or attended a care conference since coming to the facility. Review of R7's progress 11/12/25 through 2/22/26, had no mention of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · 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 ensure the ombudsman was notified following discharge from the facility for 3 of 3 sampled residents (R1, R3, and R41). Findings include: R1's 1/2/26, accepted discharge return anticipated Minimum Data Set (MDS) assessment identified he had an unplanned discharged to the hospital on [DATE]. Review of nursing progress note dated 12/17/25 at 1:47 p.m., identified R1 was sent to the hospital emergency department via ambulance for evaluation due to having poor color, lips cyanotic, and R1 was shaking. Review of nursing progress note dated 12/22/25 at 12:13 p.m., identified the facility had received a nurse-to-nurse report from the hospital. R1 was admitted to the hospital on [DATE], with diagnoses of acute hypoxia with respiratory failure. R1 returned to the facility on [DATE]. Confirmation of ombudsman notice of discharge was requested for R1; however, the facility did not provide one by the end of the survey period. R3's 2/16/26, accepted modified…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 sampled residents (R28) reviewed for unnecessary medication review. Findings include: R28's 12/29/25, accepted quarterly Minimum Data Set (MDS) assessment identified R28's cognition was intact. R28 used a walker or wheelchair for mobility and required partial to moderate assistance from staff for activities of daily living (ADL's). R28 took a daily anticoagulant medication. R28's 2/25/26, printed diagnosis list identified persistent atrial fibrillation (abnormal heart rhythm), high blood pressure, history of broken wrist, long term use of anticoagulants (blood thinner) and a history of stroke. R28's 2/24/26, Order Summary Report identified R28 took Apixaban (anticoagulant medication to prevent blood clots or stroke for people with atrial fibrillation) 2.5 milligrams twice a day for atrial fibrillation. There was no order or mention of monitoring for side effects of the anticoagulant medication that can cause bleeding, nausea, and increased…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to appropriately assess, document, and revise the care plan for 1 of 1 sampled resident (R8) who had restorative therapies identified on his care plan, but was not receiving or completing those therapies as indicated. Findings include: R8's 2/16/26, accepted quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 was noted to have impairments bilaterally on his upper and lower extremities. R8 used a wheelchair for mobility. R8 was independent with eating, required substantial assistance from staff for dressing, personal hygiene, and required total assistance from staff for toileting and bathing. R28 used a Sit to Stand mechanical device with substantial assistance from staff for transfers. R8 was not noted to ambulate. R8 had not participated in any formal type of therapy or restorative program. R8's 2/26/26, printed Medical Diagnosis list identified pulmonary disease, symptoms involving the musculoskeletal system, asthma, tremors, radiculopathy of lumbar region (compressed or irritated nerve…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · 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

    Based on observation, interview, and document review, the facility failed to re-assess nursing interventions and communicate findings for skin wound for 1 of 1 sampled resident (42) once an open area had been identified by nursing. Findings include: R42's 2/24/26, admission Record identified that R42 was admitted to the facility mid-February 2026, from an assisted living facility. R42 had diagnoses of heart failure, diabetes, dementia, high blood pressure, and a history of stroke. Interview on 2/23/26 at 1:08 p.m., with R42 identified she had a sore on the back of her right leg that the nurse kept covered because otherwise she scratched it.'R42's 2/19/26, baseline care plan identified R42 required partial assistance of one staff for cares, transfers, and ambulation. There was no mention of wounds or risk of wounds on R42's care plan. R42's 2/20/26, Weekly Skin Audit/Bath Form identified 3 small bruises on her left arm, and some bruising was noted on her lower abdomen caused by insulin injections for her diabetes. The skin audit identified there were no open lesions, cuts,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on observation, interview, and document review, the facility failed to provide services to maintain and/or prevent decrease in range- of-motion (ROM) for 1 of 1 sampled resident (R35) reviewed for limited range of motion. Findings include: R35's 8/19/2025, comprehensive Minimum Data Set (MDS) assessment identified his cognition was moderately impaired. He had diagnoses of cerebral palsy (condition primarily affecting leg movement and muscle stiffness) and dementia. R35's 2/10/26, Functional Abilities and Goals assessment identified R35 was dependent on staff for Activities of Daily Living (ADL)'s. He had no impairment to his upper extremities but was impaired on both sides of his lower extremities and used a manual wheelchair for mobility. R35's current, undated care plan identified he was at risk for decline in his physical condition related to cerebral palsy (condition primarily affecting leg movement and muscle stiffness) and was dependent on a wheelchair for mobility. The goal was for R35 to participate in a restorative exercise program to maintain his upper body strength.…

    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 · F2024-12-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review the facility failed to discard food that had expired, ensure all foods were labeled and dated, and maintain a clean fan that blew in the direction of clean dishes. This had the potential to affect all 37 residents residing in the facility. Findings include: Observation and interview on 12/16/24 at 10:44 a.m., with the dietary manager (DM) during initial tour of the kitchen. An observation of the refrigerator next to the food prep area contained 2 half gallons of milk with best use by date of 12/13/24. The DM stated the milk should have been tossed out on 12/13/24. The walk-in cooler contained 4 dishes of dessert that was not labeled or dated and a pre-made salad in a bowl that was dated 12/14/24 and was brown in color. The DM stated the dessert appeared to be carrot cake, but she was unsure of when that was last served. She confirmed that the dessert and the pre-made salad needed to be discarded. Observation and interview on 12/16/24 at 11:35 a.m., with the DM of the dishwasher room where there was a fan hanging on the wall across…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-18 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review the facility failed to ensure 1 of 2 narcotic emergency kit (E-kit) containing controlled and/or narcotic substances did not have expired medications, and ensure the E-kit contents label was updated monthly and current. Findings include: Observation on 12/16/24 at 5:40 p.m., with contract registered nurse RN-(A) of the medication room, identified a large narcotic E-kit, with a red numbered tag of 882350. RN-A stated the red tag indicated the E-kit had not been opened. If the container had a green tag, nursing staff were to use the E-kit list that was taped to the inside of the medication cabinet as a guide to fax the pharmacy of the medications that had been removed from the container and would need to be replaced. Review of July 2023 E-kit medication log identified lorazepam (treats anxiety disorders) 0.5 milligrams (mg) had an expiration date of 1/27/24, warfarin (prevent blood clots) 1 mg tablets had no expiration date listed, prednisone (reduces inflammation) 10 mg tablet with an expiration date of 1/7/24, doxycycline…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 7 citations
  • Potential for harm · D2024-12-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to obtain informed consent for psychotropic medication use for 2 of 5 residents (R32, R91) and further failed to establish a baseline assessment for monitoring abnormal involuntary movements for 1 of 1 resident (R91) who had been prescribed a new antipsychotic medication. Findings include: R32's 9/6/24, quarterly Minimum Data Set (MDS) assessment identified R32 had severe cognitive impairment, inattention, disorganized thinking, and altered level of consciousness. R32 was dependent for all cares and was frequently incontinent of bowel and bladder. R32 took a daily antidepressant, anticoagulant, and diuretic. R32's 9/17/24, diagnosis list identified Alzheimer's disease, generalized anxiety, and major depressive disorder. R32's December 2024, medication administration record identified orders for: 1) Depakote Sprinkles 125 milligrams(mg) take 2 capsules every morning for generalized anxiety disorder, unspecified dementia severe with agitation start date 11/12/24 2) Depakote Sprinkles 125 mg take 3 capsules every evening 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-14 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 41 residents. Findings include: Review of quarterly QAPI meetings from January 2023 through December 2023, identified the facility departments were submitting data to be reviewed by the committee. 2 Examples of failure to analyze and document that process identified in: 1. Quarter 2 April, may, and June of 2023, identified data brought forth that included pressure ulcers, falls, catheter use, and infections. The QAPI minutes failed to identify an analysis of that data to determine the need for improvement, a root cause, a measurable goal, or an action plan for improvement. 2. Quarter 3 July, August, and September 2023, identified data brought forth that included prevalence of falls, pressure ulcers, skin, infections, medication errors. The QAPI minutes lacked any indication that an analysis of the data had been completed 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-14 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program, with established monitoring, to help reduce unnecessary antibiotic use, reduce potential drug resistance, and help prevent the spread of infectious diseases for 5 of 12 residents (R1, R5, R17, R28, and R33) reviewed. Findings include: Review of the facility infection surveillance tracking log identified residents who had been identified as having an infection and being administered an antibiotic. The surveillance logs lacked any documentation that an antibiotic time out had been completed or the date that the infection had been resolved. 1.) R1 was identified as having a urinary tract infection (UTI), she was prescribed an antibiotic cefdinir oral capsule that started on 5/31/23. The surveillance log lacked indication that a 72 hour time out had been completed or when the infection had resolved. 2.) R5 was identified to have had a UTI, she was prescribed an antibiotic Cipro 500 mg on 8/15/23. The surveillance log lacked indication that a 72-hour time…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report immediately but not later than 2 hours, allegations of potential abuse to the State Agency for 1 of 1 residents (R4). Findings include: Review of 1/21/24 at 10:40 p.m , report to the State Agency (SA) report identified earlier on 1/21/24 at approximately 12:01 a.m., nursing assistant (NA-E) informed licensed practical nurse (LPN-C) she refused to scratch R4's genital area as R6 requested. LPN-C found R4 crying in his room and R4 stated he asked NA-E to wash his genital area and NA-E refused. R4's 1/23/24 Significant Change Minimum Data Set (MDS) identified R4 had diagnosis of Aphasia, dementia, hemiplegia/hemiparesis, anxiety and depression. R4 was cognitively intact and required maximum assist for toileting and transfers. R4 took antidepressants daily. Interview on 2/14/24 at 8:35 a.m., with director of nursing (DON) stated she was made aware of the incident the next day and NA-E did not work at the facility after the incident. Interview on 2/14/24 at 4:44 p.m., with NA-E stated she worked on 1/21/24 on the night…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to comprehensively assess and develop individualized intervention for dementia and behaviors of dementia for 2 of 2 residents (R17 and R33). Findings include: R33's 12/21/23, quarterly Minimum Data Set (MDS) assessment identified R33 had severe cognitive deficits. He had difficulty focusing his attention, had disorganized thinking, and altered level of consciousness that fluctuated. R33 had physical and verbal behaviors towards others and had refused cares 1 to 3 days during the assessment period. R33's 2/14/24, diagnosis list identified Alzheimer's disease, vascular dementia severe with agitation, major depressive disorder, restlessness and agitation, emotional lability, history of stroke, and palliative care. R33's 9/21/23, cognitive loss/dementia Care Area Assessment (CAA) identified R33 had an actual problem related to dementia and not being able to understand, answer questions or process information. R33's ability to make himself understood had declined and he displayed disorientation, confusion, and forgetfulness. R33…

    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 before2024-02-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure a system for monitoring the plastic lock on the emergency kit (E-kit) that contained controlled substances for 1 of 1 E-kits to detect potential diversion at each change of shift. Findings include: Review of the facility's ER KIT item list of what was located in the E-kit identified it contained the controlled medications of lorazepam 0.5 milligrams (mg) 6 tablets and morphine 20 mg/milliliter (ml) oral solution quantity, 15 milliliters. Observation and interview on 2/14/24 at 10:04 a.m., with licensed practical nurse (LPN)-A of the facility medication room. Locked in a cupboard was the facility E-kit with a red plastic lock with the number 882383. LPN-A revealed if the facility removed an item from the E-kit they had to fill out a form and fax it to the pharmacy. The staff would then place a green plastic lock on the E-kit those were located inside the E-kit. The pharmacy would then send a new E-kit and the facility would send the E-kit that had an item removed from it back to the pharmacy. LPN-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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R5, and R28) were offered and/or administered vaccination for pneumonia upon admission or when eligible. This had the potential to affect all 41 residents. Findings include: Review of the current Centers for Disease Control (CDC) pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) 2) Adults [AGE] years of age or older, e) Received PCV-13 at Any Age AND PPSV-23 AFTER age [AGE] Years aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 5 sampled residents for vaccinations identified: 1) R1 was [AGE] years old and was admitted to the facility in April of 2022. R2 was administered the PPSV-23 on 9/15/13, and the PCV-13 on 7/17/15. R1 should have been offered and/or provided the PCV-20 at least 5 years after…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
CLAUSEN, LINDAIndividualCORPORATE DIRECTORsince 01/30/2018
ELSING, JAMESIndividualCORPORATE DIRECTORsince 01/01/2021
GEHL, MELISSAIndividualCORPORATE DIRECTORsince 03/01/2024
JASS, SHELBYIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/19/2025
JOHNSON, LOUISEIndividualCORPORATE DIRECTORsince 02/04/2014
STEINER, JERRILDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/29/2008
VANOORT, DEANIndividualCORPORATE DIRECTORsince 01/01/2025
ZINS, SUSANIndividualCORPORATE DIRECTORsince 02/05/2019
HENNING, SHANNONIndividualCORPORATE OFFICERsince 03/01/2024
LEIBOWITZ, HOWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/12/2022

CMS files one row per role, so the 15 rows in the source record cover these 10 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.

$4.5M
Net patient revenuemost recent cost report
-25.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 4%Other / private 48%

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

$397per resident / day
operating cost
$12,059per month
≈ monthly operating cost
$317per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245570. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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