Grand Village
923 Hale Lake Pointe, Grand Rapids, MN 55744 · Government - County · 82 certified beds · (218) 326-0543 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 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 | 15.9% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.7% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.2% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.3% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.0% | 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 | 5.4% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.2% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.4% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.3% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.9% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.7% | 14.8% | 12.0% | worse |
* 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.
66.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 145 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 66.5%CMS range 59.7–73.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.1–15.3 | 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 | 83.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 86.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 77.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison 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 discharge | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.4–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 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 82 beds and averages 62.1 residents a day — about 76% occupied, or roughly 20 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 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.88 hrs/resident/day on weekends vs 4.32 on weekdays — 10% thinner on weekends. RN hours go from 1.09 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 37% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and document review the facility failed to ongoing assessment of respiratory status for 1 of 3 residents (R1) who experienced a change in respiratory status. In addition, facility staff administered medications to R1 while he displayed symptoms of respiratory distress resulting R1 requiring medications to be suctioned out of the back of his throat.Findings include: R1's face sheet printed 5/15/26, indicated he was admitted to the facility 11/12/25. Diagnoses included Traumatic subdural hemorrhage, hydrocephalus, and dysphagia. R1's 5-day Minimum Data Set (MDS) 12/22/25, identified severe cognitive impairment. MDS indicated R1 required substantial/maximal assistance to eat, displayed coughing/choking during meals and complaints of difficulty or pain when swallowing. R1's care plan dated 2/18/26, identified a self-care deficit and indicated he required assistance from staff to eat. The care plan identified altered communication and problem with nutrition related to neurological symptoms. Staff were directed to monitor/report as needed any symptoms of dysphagia…
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 · F2025-05-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed ensure beard coverings were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 68 out of 68 residents that received food out of the kitchen or kitchenette. Findings included: During initial kitchen tour on 5/19/25 at 11:19 a.m., cook-A was observed in the kitchen not wearing a beard covering. Cook-A stated he had just finished making lunch. On 5/20/25 at 8:27 a.m., cook-B was observed in a unit kitchenette serving food to residents without a beard net. Cook-B's facial hair went from below the ears to the top of the neck and under the chin, and was approximately 1.5 inches long and shaggy in areas. Cook-B stood over an open loaf of bread with one slice of bread on the countertop and putting a plate of food into the microwave. After several seconds cook-B removed the plate of food from the microwave, walked to the counter and handed the plate to another staff member who brought the plate to a resident. Cook-B stated his facial hair was long and needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to notify the physician when a weight gain of greater than 3 pounds (lbs) in 48 hours or a weight gain of greater than 5 lbs in a week was identified for 1 of 1 (R124) residents reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed staff to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of a psychotropic medications was documented for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified R42 had moderate cognitive impairment. R42 had verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated 5/21/25, identified haloperidol (typical antipsychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · 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 interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 1 of 3 residents (R24) reviewed for injectable diabetes medications. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diabetes (a disorder characterized high blood sugar levels due to either insufficient insulin production or the body's inability to effectively use insulin). The MDS identified R24 received an insulin injection and was receiving hypoglycemic medication (used to lower blood sugar levels). R24's Medication Administration Record (MAR) for the month of February 2025, identified R24 received Trulicity (a medication which increased insulin release, reduced glucagon secretion; however is not insulin) for diabetes. The February 2025, MAR did not identify R24 had received any insulin during the month. During an interview on 5/21/25 at 1:45 p.m., registered nurse (RN)-B stated the MDS was coded incorrectly and should not have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement interventions for edema for 1 of 1 resident (R124) reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25, identified the following: - On 5/17/25 at 7:51 a.m., R124 weighed 318.8 lbs. - On 5/18/25 at 11:01 a.m., R124…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or medical justification of use for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment with verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated undated, identified haloperidol (typical antipsychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure conflicting notes and orders transmission based precautions were clarified to ensure an accurate medical record was maintained for 1 of 1 resident (R127) whose medical record was found to lack admission notes. Findings include: R127's entry Minimum Data Set (MDS) dated [DATE], identified R127 was [AGE] years old and was admitted to the facility on [DATE]. R127's Diagnosis Report dated 5/21/25, identified R127 had diagnoses that included enterocolitis due to Clostridium difficile (C. diff, or costridioides difficile, is a bacterium that can cause severe diarrhea and colitis (inflammation of the colon). It is often associated with antibiotic use, which can disrupt the normal gut flora, allowing C. diff to proliferate. Symptoms of a C. diff infection can range from mild diarrhea to severe, life-threatening conditions. Treatment typically involves specific antibiotics to target the infection.) R127's History and Physical dated 5/7/25, identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed during personal cares for 1 of 3 residents (R121) whose cares were observed. Findings include: R121's 5-day Minimum Data Set (MDS) dated [DATE], identified R121 required set up to touching assistance for most care areas including toileting. R121's care plan revised 5/19/25, identified R121 required assist of one staff for toileting, dressing and grooming. During an observation on 5/20/25 at 3:02 p.m., nursing assistant (NA)-A assisted R121 to the bathroom for toileting. NA-A failed to use hand sanitizer and put on a pair of gloves R121 stood up from the toilet and NA-A stated R121 had a medium bowel movement (BM) and used a disposable wipe to clean feces from R121's buttocks. NA-A with the contaminated gloves assisted R121 to sit down on the toilet. NA-A then assisted R121 to put on a clean pull-up brief and pajama pants without completing hand hygiene or changing gloves.NA-A flushed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to perform an assessment delaying care for 1 of 3 residents (R1) reviewed for a change of condition. R1 had right arm/hand weakness on 3/23/25, was not assessed, and was sent to the hospital on 3/24/25 diagnosed with a stroke. Findings include: R1's admission Record indicated an initial admission date of 4/25/24. Diagnosis included multiple sclerosis (MS), paraplegia and a diagnosis added 3/24/25, of cerebral infarction (also known as an ischemic stroke which occurs when the blood supply to part of the brain is blocked or reduced. Symptoms include Trouble speaking and understanding what others are saying. A person having a stroke may be confused, slur words or may not be able to understand speech. Numbness, weakness or paralysis in the face, arm, or leg. This often affects just one side of the body. The person can try to raise both arms over the head. If one arm begins to fall, it may be a sign of a stroke). R1's quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-08-29 · tag F0553 — failed to let residents help plan their care — isolatedAllow 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the opportunity for an admission care conference for 1 of 3 residents (R49) reviewed for care planning. Findings include: R49's admission Minimum Data Set (MDS) assessment dated [DATE], identified R49 was cognitively intact. Diagnoses included renal insufficiency, diabetes, and arthritis. Review of R49's electronic medical record (EMR) lacked documentation of a care conference since admission to the facility. During an interview on 8/26/24 at 7:09 p.m. R49 stated he had not been invited to, or attended any care conference to discuss the plan of care (POC) since admission to the facility on 7/30/24. During an interview on 8/28/24 at 2:29 p.m. registered nurse (RN)-B stated the facility would rarely have an admission care conference. They would build the care plan and just let the resident review it after completion. Staff usually never met with the resident until closer to discharge, to discuss the discharge planning. Turn around times on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · 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 comprehensively assessed for self-administration of medications for 1 of 1 resident (R2) reviewed and observed for self-administration of medications. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. During observation on 8/27/24 at 10:46 a.m., R2 was sitting in her recliner with the nebulizer mask on her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. Nurse walked from the medication cart into R2's room, stated to R2 that the treatment was all done and shut the nebulizer machine off. Nurse washed nebulizer mask and cup and left it to air dry. During record review on 8/26/24, the self-administration of medications assessment that was completed on 7/11/24, identified R2 required frequent prompting, cues and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper wheelchair equipment was used to prevent potential complications for 1 of 1 resident (R55). Findings include: R55's significant change Minimum Data Set (MDS) dated [DATE], identified R55 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R55's diagnoses included progressive neurological conditions, degenerative disease of nervous system, non-Alzheimer's Dementia, and unspecified abnormalities of gait and mobility. During observation on 8/26/24 at 1:28 p.m., R55 left the unit with staff to go to activities. Staff assisted R55 with propelling down hallway in his wheelchair that did not have foot pedals. R55 was experiencing difficulty with holding his feet up while staff pushed wheelchair. R55's feet dropped on floor and bounces. R55's foot pedals were laying on top of dresser in room. During observation on 8/29/24 at 9:13 a.m., R55 left the unit with staff to go down to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for 1 of 2 residents (R50) reviewed for wound care. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified R50 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R50's diagnoses included hypertension, renal failure, non-Alzheimer's dementia, anxiety disorder and other symptoms and signs involving the musculoskeletal system. MDS also identified that R50 was at risk for developing pressure ulcers/injuries and is on turning and repositioning program. R50's care plan undated, identified R50 had altered skin integrity related to fragile skin due to closed lumbar fracture and was at risk for the development of pressure ulcers. R50's care plan directed staff to reposition R50 every two hours while in bed and/or wheelchair. During continuous observations on 8/27/24 from…
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 · D2024-08-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to facility policy and failed to ensure nebulizer tubing/cannister was cleaned and allowed to air dry after each use for 1 of 1 resident (R38) reviewed for oxygen therapy. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact and had continuous oxygen therapy since admission to the facility. R38's provider order dated 8/13/24, identified oxygen at 2 liters/minute by nasal cannula (NC) continuously and budesonide inhalation suspension 0.5 milligrams/2 milliters inhaled via nebulizer two times a day. R38's care plan dated 8/7/24, identified R38 needed continuous oxygen therapy and to administer oxygen and respiratory medications as per orders. The care plan lacked documentation when to change oxygen tubing and when/how to clean nebulizer tubing/cannister. R38's treatment administration record for 8/24 indicated oxygen tubing and nasal cannula…
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 · D2024-08-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited order and failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 1 residents (R4) reviewed for hospice. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R4's diagnoses included non-Alzheimer's dementia, anxiety disorder, nutritional deficiency, and chronic pain. R4's physician orders included orders for lorazepam 0.5 milligram (mg) every four hours as needed. This order was initiated on 3/8/24 and was open-ended. Orders also included risperidone (antipsychotic) 0.25 mg by mouth two times daily for obsessive itching/picking related to generalized anxiety disorder. R4's medical record was reviewed and lacked any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for medication errors received physician ordered medications. In addition, the facility failed to notify the physician of the missed medications. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included atrial fibrillation, chronic kidney disease and hypertension. R1's care plan dated 7/9/24, identified an alteration in health status and directed staff administer medications per physicians order. R1's Order Summary Report printed 7/31/24, identified the following order dated 7/9/24: Slow Magnesium/Calcium oral tablet delayed release 70-117 milligram, give two tablets one time a day for hypomagnesemia. R1's Medication Administration Record for July 2024, indicated she received the medicaion on 7/10/24, 7/15/24 and 7/29/24. All other days staff indicated she did not receive the medication. R1's Hospitalist Discharge summary dated [DATE], indicated she admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-12 · 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
Based on observation, interview and document review the facility failed to implement a process for conducting routine maintenance of rehabilitation equipment. This had the potential to affect all residents in the facility who received rehabilitation services. Findings include: On 9/12/23, at 1:07 p.m. A standing frame in the facility wellness center was observed. The standing frame had a sign on it that indicated out of service, do not use. During interview on 9/12/23, at 1:11 p.m. the physical therapy assistant (PTA) program manager stated the maintenance department had taken the standing frame out of commission. The PTA stated there was supposed to be a back support on the frame and said the facility was unable to locate it and was unable to purchase one. The PTA stated he had worked at the facility three years prior and did not believe he had ever seen the back support. The PTA stated the missing back support would not have contributed to the injury that prompted the inspection of the standing frame. During interview on 9/12/23, at 1:17 p.m. the restorative aide, nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF ITASCA | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/13/2015 |
| JOHNSON, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| ROHLING, AUSTIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SMITH, CORY | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SNYDER, TERRY | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| TRUNT, LEO | Individual | CORPORATE DIRECTOR | — | since 01/01/2010 |
| VENEMA, MATTHEW | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| EBENEZER MANAGEMENT SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/30/2025 |
| BELL, BRITTANY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| OLIVERIUS, MAGGIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/21/2025 |
| WILLETT, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| YOUNGDAHL-PALECEK, ANTOINETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/21/2025 |
CMS files one row per role, so the 15 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 245368. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-07, 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.