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Regina Senior Living

1175 Nininger Road, Hastings, MN 55033 · Non profit - Corporation · 57 certified beds · (651) 480-4333 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Feb 20261 immediate-jeopardy citation$15,919 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,919 in federal fines (most recent 2023-08-22)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1175 Nininger Rd · (651) 480-4100 · Call to confirm hours
Pharmacy
1399 S Frontage Rd · (651) 438-7960 · Call to confirm hours
Grocery
1250 S Frontage Rd · (651) 437-2667 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1046 W 5th St · (651) 480-2273

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
Short-stay residentsrehab / post-hospital 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 3 to 2 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 rating2★
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 increased25.0%18.2%15.4%worse
Long-stay residents who lose too much weight4.1%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.9%1.9%0.9%typical
Long-stay residents with a urinary tract infection7.5%2.6%2.0%worse
Long-stay residents with depressive symptoms0.7%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 injury1.2%4.0%3.3%better
Long-stay residents whose ability to walk worsened34.6%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication4.8%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.0%5.2%4.7%typical
Long-stay residents with worsening bladder/bowel control20.5%24.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.9%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine97.8%82.7%79.4%better
Short-stay residents rehospitalized after admission24.6%23.5%22.6%typical
Short-stay residents with an outpatient ER visit24.0%14.8%12.0%worse

§ 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.

51.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.8%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
50.8%U.S. median 56.6%
Met the expected recovery
0.70U.S. median 0.31
Therapy hours / resident / day
0.38hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 50.8% 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 65 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 0.70 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.8%CMS range 44.8–64.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.9–14.810.7%Oct 2022–Sep 2024no 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 discharge50.8%56.6%Oct 2024–Sep 2025CMS 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 discharge46.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.3%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay2.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.3–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

0.90
RN hours/ resident / day
0.59
LPN hours/ resident / day
1.96
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.61
RN hoursweekends
43.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 57 beds and averages 50.1 residents a day — about 88% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 2.98 hrs/resident/day on weekends vs 3.63 on weekdays — 18% thinner on weekends. RN hours go from 1.01 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

7
deficiencies at the latest standard inspection (2026-02-26)
10
at the previous standard inspection (2025-03-20)

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.

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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · J2023-10-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for 1 of 1 resident (R1) reviewed for pressure ulcers. R1 admitted to the facility without pressure ulcers, subsequently developed an unstageable pressure ulcer related to necrotic (death of tissue). The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration, and notify R1's provider of changes, resulting in R1 being hospitalized . The immediate jeopardy began on 8/15/23, when a pressure ulcer was noted to R1's buttocks without proper assessment, physician notification, and documentation of interventions and was identified on 10/4/23. The administrator and director of nursing (DON) were notified of the on 10/4/23 at 4:55 p.m. The immediate jeopardy was removed on 10/6/23 but noncompliance remained at the lower scope and severity level 2, D - isolated scope and severity level, which indicated no actual harm with potential for more than…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess and evaluate the appropriateness of the colostomy care supplies and ensure proper fitting of the wafer to prevent leakages and failed to provide physician-ordered care for colostomy care for one resident (R1). This failure caused psychosocial harm to R1 when his colostomy care was delayed, and he suffered emotional distress and suicidal ideation. Findings include:On 7/15/25, at 10:21 a.m., R1 stated he had several episodes of his colostomy leaking in the first few weeks at the facility. R1 stated he repeatedly asked the facility to use the products he was familiar with, including rings (intended to create a secure and comfortable seal between an ostomy pouch and the skin around the stoma, to prevent leakage) and wings (small flexible pieces of hydrocolloid adhesive that attach to the edges of an ostomy skin barrier to provide extra security and prevent leaks). R1 stated the facility started providing the requested supplies, after he became…

    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 · Fcited before2026-02-26 · 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 and interview, the facility failed to clean and sanitize food-contact equipment, remove a paper bowl used as a scoop in a sugar container and keep food boxes off walk-in freezer unit floor. Findings include: During the initial kitchen tour on 2/23/26 at 12:15 p.m., with the culinary director (CD), the following was identified: seven boxes were stored on the Walk-in freezer floor, a brown paper bowel used as scoop left in the sugar container and the can opener part that meets the top of the can (blade and gear) was covered with dark dry substance. CD confirmed the scoop in the sugar container, is not the usual practice indicated it could cause for cross contamination. During a follow up kitchen tour 2/25/26 at 7:52 a.m., the can opener blade and gear remained covered with the dark dry substance and additionally a red paste was noted on the blade. Head cook (HC) indicated it was used and must have gotten dirty yesterday.In the walk-in freezer, five food boxes remained on the floor. HC stated the boxes were not supposed to be on the floors and were delivered 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 · Ecited before2026-02-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to correctly establish and ensure staff followed appropriate transmission-based precaution (TBP) for 1 of 1 resident (R66) who required enhanced respiratory precautions for COVID-19. Further, the facility failed to ensure appropriate personal protective equipment (PPE) was used for residents in enhanced barrier precaution (EBP) during podiatry treatments in a common area for 1 of 3 residents (R57) reviewed for EBP. Additionally, the facility failed to initiate EBP for 1 of 1 resident (R33) who required EBP due to a pressure ulcer.Findings include: R66 was admitted to the facility on [DATE] from a hospital, her Minimum Data Set (MDS) assessment had not been completed at time of survey. R66's progress note dated 2/21/26 indicated R66 had severe cognitive impairment. R66 had a diagnosis of dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities)…

    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 · Dcited before2026-02-26 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review the facility failed to ensure privacy was maintained during treatments for 3 of 3 residents (R29, R54, R57) reviewed for privacy.Findings include:During an observation on 2/23/26 at 1:19 p.m., R57 was in the facility day room receiving podiatry (foot)cares. R54 and R29 were in the day room waiting for their podiatry appointments. Upon completion of foot care, R57 was removed from room by the podiatry medical assistant (MA)-A. MA-A returned and moved R54 so his foot cares could be completed. R29 remained in the day room during R54's podiatry treatments. Once completed R54 was assisted out of the room by facility staff. MA-A then moved R29 so she could have her podiatry cares completed. During R29's podiatry treatment, nursing staff and cleaning staff were walking through the day room. Upon completion, R29 was taken back to her room by facility staff.R29's quarterly Minimum Data Set (MDS)assessment, dated 1/8/26, indicated R29 had severe cognitive impairment. Further, R29 was dependent on facility staff for all cares. R29's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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

    Based on interview and record review, the facility failed to ensure an evaluation was completed prior to renewal of PRN (as needed) antipsychotic medications for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) assessment, dated 2/10/26 indicated R10 had severe cognitive impairment with a history of verbal behaviors. The MDS also indicated R10 was receiving hospice care and received antipsychotic medications (medications used to treat mental health disorders and behavioral disturbances). R10's diagnoses list included, unspecified dementia, cognitive communication deficit, anxiety, protein-calorie malnutrition.R10's care plan indicated mood state related to diagnosis of anxiety and restlessness and agitation, high risk medications including Haloperidol (antipsychotic medication), hospice services, and cognitive loss related to dementia.R10's medication administration record indicated R10 received haloperidol 1 mg every 4 hours PRN from 1/26-2/8 (21 doses given), haloperidol 1 mg every 1 hour 2/10-2/12 (4 doses…

    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 · Dcited before2026-02-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 2 residents (R24, R33) reviewed for care planning.Findings include: R33's admission Minimum Data Set (MDS) assessment, dated 1/14/26, indicated intact cognition. R33 required substantial assistance with toileting and bed mobility, was occasionally incontinent of bladder and continent of bowel. R33 was at risk for a pressure ulcer, had no pressure ulcer/injury on admission. R33 had a pressure reducing device for chair and bed. R33's diagnoses included, cerebral infarction (CVA) (blood clot in the brain), pressure induced deep tissue damage of left heel, chronic systolic (congestive) heart failure (a serious condition of the heart's ability to pump blood efficiently), and edema (swelling). R33's admission skin risk assessments, dated 1/8/26 indicated at risk for pressure ulcers with an intervention to reposition every two to three hours. R33's care plan dated 1/12/26, indicated R33 needs…

    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 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medications were available for administration per physician order for 2 of 2 residents (R1, R54) reviewed for pharmacy services. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact with no behaviors, have pressure reducing devices, nutritional supplementation, and dressings. R1 was independent with eating, set up for oral hygiene and required assistance for all activities of daily living. R1's care plan indicated R1 had wounds to both feet, impaired cardiac output, enhanced barrier precautions related to wounds, and diabetes, R1's diagnoses list included, cerebral palsy (brain disorder causing decreased muscle coordination) , peripheral vascular disease (disorder affecting circulation in the arms and legs), diabetes (disorder affecting blood sugar levels), respiratory failure (disorder affecting breathing), lymphedema (disorder causing fluid collection under the skin), and venous…

    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 · Dcited before2026-02-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to monitor for effectiveness of a medication prescribed for sleep for 1 of 5 residents (R47) reviewed for unnecessary medications. Findings include: R47's Minimum Data Set (MDS) assessment, dated 12/2/25 identified R47 had no cognitive impairment, had lower extremity impairment on one side, maximum assistance with transfer and bed mobility, independent with toilet transfer, incontinent of bowel and bladder.R47 diagnoses include polyneuropathy (a condition in which multiple peripheral nerves are damaged, leading to weakness, numbness and impaired function in various parts of the body), type 2 diabetes, major depressive disorder, anxiety, obstructive sleep apnea, and laceration to right great toe. R47's medication orders included: Melatonin tablet 5 milligram (mg), oral at bedtime: Start date 11/22/24. R47's Medication Administration Record (MAR) record review from 1/01/26 to 1/31/26 and 2/01/26 to 2/25/26 indicated medication was administered. R47's record lacked sleep tracking or monitoring assessment. During an interview on…

    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 · D2025-07-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to offer a care conference during 1 of 3 residents (R1) reviewed for ostomy care. This resulted in R1's inability to participate in his care planning.Findings include:R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care.R1's medication administration record (MAR), dated June and July 2025, directed to change ostomy bag two times weekly and as needed for leakage, on Monday and Wednesday evenings.R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease (chronic inflammatory bowel disease) and had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface). R1's MDS indicated he was cognitively intact.R1's chart lacked documentation of a care conference.On…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop and implement a comprehensive, individualized care plan for 1 of 3 residents (R1) reviewed for ostomy care. The facility failed to have a process in place to instruct staff on physician ordered ostomy care. This resulted in R1's colostomy bag leaking on multiple occasions and emotional distress for R1.Findings include: R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care.R1's medication administration record (MAR), dated June and July 2025, directed to change ostomy bag two times weekly and as needed for leakage, on Monday and Wednesday evenings.R1's bowel assessment, dated 6/8/25, failed to appropriately assess his ostomy site with measurements and description.R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-15 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) reviewed for ostomy care, received colostomy care as ordered by the physician. This resulted in inappropriate care, as evidenced by frequent leakage incidents for R1.Findings include: R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care. R1's after discharge orders from the hospital, dated 6/5/25 directed:Procedure for pouch change:1) Prepare new pouch, using a Coloplast 16716 or your normal pouches. Opening should be 1/16- 1/8 larger than the stoma. Set pouch aside.2) Remove old pouch, and discard.3) Cleanse peristomal area with warm water only and Versalon 4 x 4's (#118746). *Do not use soap, wipes, adhesive remover, or skin prep to cleanse peristomal skin.4) Allow skin to dry. At this point - CRUST the peristomal skin 1x. See below…

    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
Show the remaining 18 citations
  • Potential for harm · Fcited before2025-03-20 · 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 ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. In addition, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed, and failed to monitor sanitation level of the three-compartment sink and cleaning of food equipment. This deficient practice had the potential to affect all 53 residents who received food from the refrigerators and the kitchen, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher. Findings include: Label, cover and date: During an observation and interview on 3/17/25 at approximately 7:15 p.m., there were two large clear plastic undated containers with Raisin Bran and [NAME] Krispies. The regional director clinical services (RDCS) verified the cereal should be labeled and dated. The RDCS requested dietary aide (DA)-A to throw the unlabeled cereal as there…

    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 · E2025-03-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview and policy review, the facility failed to ensure medications were securely and safely stored and under direct observation of authorized staff in areas where residents, staff and guests could access them. This had the potential to affect 37 residents whose medications were stored in the cart. Findings include: During observation on 3/17/25 at 6:15 p.m., an unattended and unlocked medication cart was observed in alcove across from resident room with no staff in sight. One female resident in wheelchair wheeled past the cart. At 6:22 p.m., nursing assistant (NA)-A walked towards the medication cart and stated, Yeah it is unlocked. Anyone can get in there [pointing to the medication cart] if they want. Registered nurse (RN)-A walked around the corner and approached the medication cart. RN-A stated it was her cart and verified, it is unlocked. Should not be because anyone can get in there and get narcotics and other medications. During observation and interview on 3/18/25 at 9:38 a.m., an unlocked and unattended medication cart was observed between two…

    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 · D2025-03-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dignity was maintained for 3 of 3 residents (R24, R51, R151) observed for long call light response times. Findings include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had intact cognition, did not reject cares, and required substantial to maximal assistance with toileting hygiene and upper and lower body dressing. In addition, R24's medical diagnoses include paralysis on left side from stroke, and depression. During continuous observation and interview on 3/19/25 from 12:42 p.m., to 1:11 p.m., for a total of 28 minutes and 48 seconds, R24 call light was activated and beeping outside R24 room before staff entered room. During interview at 1:27 p.m., R24 stated she had turned on the call light for changing [sic] brief. It is frustrating for me to wait to have [staff] answer my light. I have to wait and wait. My brief was dirty and I had to sit in it until [staff] got around to it. Made me feel gross. R51 R51's face sheet…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 medical provider of a change in condition in a timely manner for 1 of 1 resident (R11) reviewed for respiratory care. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition, and was dependent on staff for toileting, bathing, dressing, and personal hygiene. In addition, R11 had diagnoses of diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease and was utilizing oxygen. R11's physician orders (PO) with start dates of 8/31/23, identify the following: -Guaifenesin liquid; 100 milligrams (mg)/5 milliliters (ml); Amount to administer: 10 ml; oral. Every 4 hours-porn (as needed) for cough, and -Benzonatate capsule; 100 mg; Amount to administer: 100 mg; oral every 4 hours prn. take 1 Every (q) 4 hours prn for cough. R11's February 2025 Medication Administration Record (MAR) identified no administration of Benzonatate or Guaifenesin. R11's March 2025 MAR identified first…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident identifiable personal health information (PHI) was kept secured and not accessible to unauthorized personnel. This had the potential to affect 2 of 2 residents (R31, R37) whose personal information was listed on exposed care sheets. Findings include: R31 R31's quarterly Minimum Data Set (MDS) dated [DATE] identified R31 with intact cognition. R37 R37's quarterly MDS dated [DATE] identified R37 with intact cognition. During continuous observation on 3/20/25 from 6:28 a.m., to 7:19 a.m., a care sheet was left unattended in an alcove across the hall from nursing station. The care sheet identified R31 and R37 with name, room number, diet, allergies, assistance needed with personal care, days of showers and weights, preferences reminders, transfer assistance needed, and reminders for bowel and bladder monitoring. During fifty-one minutes there were seventeen instances of staff walking past and four instances of residents being wheeled past 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure voiced grievances and complaints about the offsite laundry service were acted upon and, if needed, investigated or resolved for 1 of 1 resident (R2) reviewed who complained their clothing was missing or damaged due to the service. Findings include: R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition and demonstrated no delusional thinking during the review period. On 3/18/25 at 9:53 a.m., R2 was interviewed and expressed frustration with the facility's laundry service which was completed offsite. R2 explained she stated many of her clothing items taken through the service, and several items such as various shirts and pants, either didn't return until several weeks later, didn't return at all, or were damaged with holes in them upon return. R2 stated they had talked with staff about it but had been told there was nothing they [staff] can do about it. R2 stated her voiced concerns remained unresolved to her…

    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 · D2025-03-20 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and depressive symptoms were evaluated for 2 of 4 residents (R36, R12) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the RAI consists of three basic components including the MDS, the Care Area Assessment (CAA) and the utilization guidelines and this process (i.e., use of the entire RAI) was mandated by CMS. The manual outlined a quarterly assessment was a non-comprehensive assessment which was to be completed every 92 days and was used to track a resident' status between comprehensive assessments . to ensure critical indicators of gradual change in a resident's status are monitored. The manual included a section labeled, SECTION C: COGNITIVE PATTERNS, which outlined the section would be…

    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 · Dcited before2025-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview and record review, the facility failed to comprehensively assess and monitor a resident with new onset of respiratory symptoms for 1 of 1 residents (R11) reviewed for respiratory complications. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE] identified R11 had intact cognition, was dependent on staff for toileting, bathing, dressing, and personal hygiene. In addition, R11 had diagnoses of diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease and was utilizing oxygen. R11's physician orders (PO) with start dates of 8/31/23, identify the following: -Guaifenesin liquid; 100 milligrams (mg)/5 milliliters (mL); Amount to administer: 10 ml; oral. Every 4 hours-prn (as needed) for cough, and -Benzonatate capsule; 100 mg; Amount to administer: 100 mg; oral every 4 hours prn. take 1 Every (q) 4 hours prn for cough. R11's PO with start date of 1/29/25, identified: Proventil HFA (albuterol sulfate) HFA aerosol inhaler; 90 mcg/actuation; Amount 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained for 1 of 3 residents (R12) reviewed for EBP. Furthermore, the facility failed to implement and maintain respiratory precautions and have proper infection survelliance for 1 of 1 resident (R11) reviewed who had active symptoms of a potential respiratory illness. Findings include: EBP The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities. The article indicated high-contact activities include providing hygiene, changing briefs, dressing, urinary catheter care, etc. The article indicated that EBP should be…

    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 · D2024-01-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 monitor and maintain oxygen and nebulizer tubing and mask for 1 of 1 resident (R4) reviewed for respiratory care. Findings include: R4's annual Minimum Data Set (MDS), dated [DATE], indicated R4 was cognitively intact and required maximum assistance with toileting, personal hygiene, and lower body dressing and moderate assistance with bathing and upper body dressing. R4's Physician Orders indicated an order, dated 5/8/23, for oxygen at 2 liters per minute as needed to maintain oxygen saturation at or greater than 90%. The Physician Orders also indicated an order, dated 1/6/24, for albuterol sulfate solution for nebulization, inhale twice a day. R4's electronic medical record (EMR), including Physician Orders, Medication Administration Record, Treatment Administration Record, and Care Plan, were reviewed and lacked interventions to change the oxygen tubing, nasal cannula, nebulizer tubing and nebulizer mask. During observation and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to offer or attempt non-pharmacological interventions for pain prior to administering as needed (PRN) pain medications for 1 of 5 residents (R254) reviewed for unnecessary medications. Findings include: R254's Face Sheet, dated 1/25/24, indicated R254 was admitted to the facility on [DATE] with the following diagnoses; malignant neoplasm of pharynx and hypopharynx (throat cancer), secondary neoplasm of the right and left lung (lung cancer), throat pain and unspecified pain. R254's Physician Order Report, dated 1/25/24 indicated an order for hydromorphone (an opioid used to treat moderate to severe pain) 2 milligram (mg) tablet, give 1 tablet by mouth every 6 hours scheduled and every 4 hours PRN. R254's pain assessment, dated 1/13/23, listed not applicable (NA) for non-pharmacololgical pain interventions under the symptom managment interventions section. R254's initial care plan was reviewed and lacked interventions to address R254's pain, including…

    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 · Dcited before2024-01-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to prevent the potential for and increased risk of a urinary tract infection by placing catheter bag on the floor for 1 of 1 residents (R3) reviewed for catheter care. Findings include: R3's Minimum Data Set (MDS) indicated R3 had moderate cognitive impairment and did not have behaviors. The MDS also indicated R3 needed partial assistance with oral hygiene and eating; substantial assistance with personal hygiene, bathing, upper body dressing and mobility and was dependent with toileting and lower body dressing. R3's Face Sheet dated 1/25/24, indicated R3 had diagnoses of Parkinson's disease with dyskinesia, polyosteoarthritis(condition characterized by joint pain and stiffness) , flaccid neuropathic bladder (condition that leads to urinary retention or the inability to fully empty the bladder), urinary retention (difficulty urinating and completely emptying the bladder) , inflammatory polyarthropathy (pain and inflammation in more than 5 joints) and pulmonary hypertension (a type of blood pressure that affects…

    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 · D2024-01-25 · 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 2 of the 5 residents (R2 and R29) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R2's facility immunization record, dated 01/24/24, indicated she was [AGE] years old. The record indicated she received a PCV13 on 6/15/2008…

    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 · Dcited before2023-10-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 record review, the facility failed to notify 2 of 3 (R1 & R2) residents' physician and representative of a significant change in status when R1 developed a pressure ulcer and R2 had an abrasion to his back that required ongoing treatment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, required extensive assistance for bed mobility and transfers, and was not ambulatory. The MDS indicated R1 was at risk for pressure ulcers, had diagnoses of Multiple sclerosis, weakness and abnormal posture and required the extensive assistance of one staff for bed mobility, dressing and toileting. A Nurse Practitioner (NP) note dated 7/27/23, indicated R1 had several wounds to bilateral buttocks near coccyx that an in house wound physician (WMD) was following. During an interview on 10/2/23, at 1:56 p.m. FM-B stated she didn't know about the pressure ulcer until just prior to R1 going to the hospital on 8/24/23, she recalled that she was told by…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a resident received treatment and care when a wound physician ordered daily wound care for 1 of 3 residents (R2) reviewed for quality of care. R2's physician orders were not transcribed into the electronic medical record (EMR) and was not performed. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], noted R1 had intact cognition and required extensive assist of one staff for bed mobility, toileting, and dressing, supervision with transfers and personal hygiene. R2 had diagnoses that included malignant neoplasm of prostate, weakness ad difficulty walking. A progress note dated 9/28/23, indicated R2 was seen on weekly wound rounds with wound nurse (LPN)-A and the wound physician (WMD), R2 had an abrasion noted to his middle back, wound orders were as follows: 1. Cleanse with wound cleanser 2. Skin prep to peri wound 3. Apply xeroform to affected area 4. Cover with island gauze 5. Initial and date dressing. A VOHRA wound…

    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 before2023-08-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff maintained infection control prevention with the proper use of gloves, hand hygiene, and handling of wound supplies during a dressing change for 1 of 3 residents (R1) reviewed with an infection present. Findings include: CDC: Healthcare Providers | Hand Hygiene, www.cdc.gov/handhygiene/providers/index.html indicated to perform hand hygiene prior to starting wound care for each resident: This includes before retrieving wound care supplies, before donning gloves, and after doffing gloves. Wound care prevention recommendations for long term care facilities. Alcohol-based hand rub (ABHR) should be readily accessible throughout the wound care process. Unless hands are visibly soiled, alcohol-based hand rub is preferred over soap and water. Health care workers should not touch items in the resident care environment while performing wound care as this will contaminate gloves, supplies, and/or the environment. Hand hygiene must be…

    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
  • No harm found · B2025-03-20 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 2 residents (R7 and R30), reviewed for hospitalization. This had the potential to affect all residents who were hospitalized . Findings include: R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had intact cognition and was independent with activities of daily living (ADL)'s. R30's diagnoses included heart failure, hypertension, renal failure, anxiety disorder and personal history of transient ischemic attack. R30's clinical record indicated R30 was hospitalized from [DATE], through 3/13/25. R30's discharge MDS dated [DATE], indicated R30 had an unplanned discharge to a short-term general hospital and return was anticipated. R30's progress notes indicated R30 was transferred to the hospital with signs and symptoms of pneumonia on 3/11/25. R30's entry tracking MDS dated [DATE], indicated R30 returned from short-term general hospital on…

    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
  • No harm found · B2025-03-20 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 a written bed hold for 2 of 2 residents (R7 and R30) reviewed for hospitalization. Findings include: R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had intact cognition and was independent with activities of daily living (ADL)'s. R30's diagnoses included heart failure, hypertension, renal failure, anxiety disorder and personal history of transient ischemic attack. R30's clinical record indicated R30 was hospitalized from [DATE] through 3/13/25. R30's discharge MDS dated [DATE], indicated R30 had an unplanned discharge to a short-term general hospital and return was anticipated. R30's progress notes indicated R30 was transferred to the hospital with signs and symptoms of pneumonia on 3/11/25. R30's entry tracking MDS dated [DATE], indicated R30 returned from short-term general hospital on 3/13/25. However, R30's record lacked evidence of a bed hold being discussed with resident or representative at time of transfer on…

    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

“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

$15,919 in federal fines across 1 penalty.

  • $15,919 — penalty dated 2023-08-22

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BENEDICTINE HEALTH SYSTEM — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 2 of 52.9-0.9 vs chain
The other 22 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
STURM, BRIANAIndividualCONTRACTED MANAGING EMPLOYEEsince 05/24/2021
BRUHN, JENNIFERIndividualCORPORATE DIRECTORsince 11/25/2019
CONZEMIUS, NICHOLASIndividualCORPORATE DIRECTORsince 01/13/2014
ESTENSON, BERNEDETTEIndividualCORPORATE DIRECTORsince 10/10/2016
JURGENS, TONYIndividualCORPORATE DIRECTORsince 09/01/2018
LASELLE, ANTHONYIndividualCORPORATE DIRECTORsince 05/15/2017
NIEBUR, THERESAIndividualCORPORATE DIRECTORsince 10/10/2016
BERGIEN, TRICIAIndividualCORPORATE OFFICERsince 11/18/2016
RYMANOWSKI, KEVINIndividualCORPORATE OFFICERsince 09/20/2013
BENEDICTINE HEALTH SYSTEMOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2013
CARLEY, GERALDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/18/2017

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$7.6M
Net patient revenuemost recent cost report
-92.3%
Operating marginrevenue minus expenses
$697K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 8%Other / private 44%

This home reported $697K paid to related parties (affiliated landlords or management companies) in its most recent 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 2024. 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

$794per resident / day
operating cost
$24,123per month
≈ monthly operating cost
$413per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 245254. 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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