Chapel View Health Care Center
615 Minnetonka Mills Road, Hopkins, MN 55343 · Non profit - Corporation · 100 certified beds · (952) 938-2761 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,345 in federal fines (most recent 2025-04-24)
- its payroll-based staffing score sits well above its independent inspection score
- about 20% of its spending goes to commonly-owned related companies
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 4 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 | 17.8% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.5% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.4% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.5% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.2% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 4.4% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 5.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.3% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.2% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.9% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.0% | 14.8% | 12.0% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.9% 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 266 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.3% 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 116 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% 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 | 62.9%CMS range 57.1–69.6 | 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 | 10.5%CMS range 8.2–13.6 | 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 | 54.3% | 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 | 50.0% | 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 | 42.2% | 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 | 98.8% | 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 | 87.9% | 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 | 95.6% | 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 | 2.5% | 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 | 1.9% | 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 | 6.2%CMS range 4.0–9.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 100 beds and averages 91.1 residents a day — about 91% occupied, or roughly 9 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.34 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.91 hrs/resident/day on weekends vs 4.47 on weekdays — 12% thinner on weekends. RN hours go from 1.47 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Lcited before2025-04-24 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 implement infection control strategies for respiratory protection to mitigate the risk and spread of Influenza A. As a result, the facility developed an outbreak where 13 residents (R1, R2, R3, R4, R5, R6, R7, R9, R13, R8, R10, R11 and R12) tested positive for Influenza A. Five residents (R1, R2, R5, R10 and R15) were sent to ED and admitted to hospital, These practices resulted in an immediate jeopardy (IJ) due to the likelihood of spread to the remaining 80 residents in the facility. The IJ began on 3/31/25, when the facility failed to implement ongoing monitoring, screening of residents with respiratory symptoms and implement transmission-based precautions and was identified on 4/18/25. The Administrator, director of Nursing (DON), and regional nurse consultant (RNC), were notified of the immediate jeopardy at 11:50 a.m. on 4/23/25. The immediate jeopardy was removed on 4/19/25 and the deficient practice corrected on 4/19/25, prior 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.
- Actual harm · Gcited before2026-04-16 · 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 interview and document review, the facility failed to follow practitioner orders for 1 of 3 residents (R3) reviewed for respiratory care when R3 was sent to an off-site appointment without oxygen, resulting in a change in her condition requiring hospitalization.The noncompliance that began on 1/27/26 was corrected prior to the start of survey when the facility implemented a corrective action plan on 1/27/26. This is issued in past noncompliance. Findings include:R3's quarterly Minimum Data Set MDS), dated [DATE], indicated she had diagnoses of morbid obesity with alveolar hypoventilation (a condition where breathing is shallow or slow), hypertensive kidney disease, lymphedema (tissue swelling caused by fluid that is usually drained by the body's lymphatic system), atrial fibrillation, (an irregular heart rhythm), venous insufficiency and hypoxemia (low levels of oxygen in the blood).R3's care plan, dated 1/23/26, directed administer oxygen (O2) per orders.A nurse practitioner (NP) visit note, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R4) whose wheelchair was soiled. In addition, the facility failed to maintain resident equipment cleanliness of intravenous (IV) poles for 2 of 4 residents (R40 and R98) reviewed for tube feeding. Findings include:Wheelchair:R4's annual Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, and required extensive assistance with cares. The MDS identified R4 had diagnoses of hemiplegia (paralysis of one side of body), diabetes, spondylosis (age-related degeneration of the spine), and osteoarthritis. The MDS indicated R4 used a wheelchair for locomotion. R4's current care plan revised 9/10/25, identified R4 required assistance with wheelchair mobility for partial distance and off the unit due to impaired mobility and left sided hemiplegia, uses left side foot rest only with left arm rest. During observation on 12/01/2025, at 11:51am. R4 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · 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 comprehensively assess and appropriately monitor 2 of 3 residents (R5, R13) with acute illnesses including but not limited to influenza that resulted in hospitalization reviewed for change of condition. Findings include: See F880 for additional information about facility's infection control and prevention practices regarding influenza. R5 R5's quarterly Minimum Data Set, dated [DATE], indicated R5 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, type 2 diabetes, hyperkalemia (elevated blood level of potassium), and acute and chronic respiratory failure. R5 used supplemental oxygen therapy and was cognitively intact. R5's care plan problems dated 7/7/23, identified R5 was at risk for decline in medical condition with intervention to monitor for changes in condition and notify provider and resident representative as indicated. R5's care…
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 before2025-04-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure a system to ensure physician orders were accurately transcribed to prevent and/or mitigate risk of medication errors for 1 of 2 residents (R17) reviewed for medication errors. The facility's failures resulted in R17 received ibuprofen 66 times not in accordance with physician orders. Findings include: R17's face sheet dated 4/24/25, indicate the following diagnoses of status post stroke, and aneurysm of left internal carotid artery. R17's interagency transfer form dated 4/2/25, included an order for ibuprofen (IBU- (a nonsteroidal anti-inflammatory drug used to treat mild to moderate pain. Side effects include headache, dizziness, nausea, bleeding, and bruising)) 400 mg every 6 hours as needed (PRN) for pain. R17's provider visit summaries dated 4/4/25 and 4/14/25, included and identified an order for (IBU) 400 mg every 6 hours PRN for fever. R17's electronic health record (EHR) identified the aforementioned physician order for as needed IBU however was not accurately transcribed into the EHR system. The order that…
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 · D2025-04-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 that a resident was free from a significant medication error for 1 of 3 residents (R15) reviewed for medication errors. Findings include: R15's face sheet dated 4/24/25, indicated diagnoses of fractured left femur, status post hemiarthroplasty (hip replacement) left hip, acute respiratory failure with hypoxia, and acute bronchitis due to respiratory syncytial virus (RSV). R15's hospital discharge summary indicated R15 was admitted to the hospital on [DATE] and discharged to the facility on 4/17/25. The discharge orders that had been faxed to the facility on 4/17/25, identified two separate Dilaudid (opioid narcotic pain killer) orders: -Order signed by physician on 4/14/25, identified an order for Dilaudid 2mg tablets to take 1 to 2 tablets every 4 hours as needed for pain; take 1 tablet for pain rate 4-7 out of 10. Take 2 tablets for pain rate 8-10 out of 10 -Order signed by physician on 4/17/25, identified an order for Dilaudid 2 mg tablets 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 · D2025-04-24 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 physician orders for laboratory studies had been obtained in a timely manner for 3 of 3 residents (R5, R13, R15) who had physician ordered labs. Findings include: R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had diagnoses including type 2 diabetes, hyperkalemia, congestive heart failure, and acute and chronic respiratory failure. R5's care plan dated 7/7/23, identified she was at risk for decline in medical condition. Interventions included administering medications and treatments per physician orders and monitoring for changes in condition and notifying provider as indicated. R5's progress note by licensed practical nurse (LPN)-A dated 4/8/25 at 12:21 p.m., indicated R5 had a change in condition and the provider was notified. The provider ordered STAT (immediately, without delay) laboratory (lab) studies of CBC (complete blood count, a blood draw study), BMP (basic metabolic panel, a blood draw study), COVID-19, RSV…
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 · D2025-04-24 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 promptly notify the ordering physician of an abnormal laboratory result for 1 of 3 residents (R13) who had laboratory orders. Findings include: R13's nurse practitioner (NP) note dated 4/9/25, indicated R13 was seen for an acute visit by NP-A regarding a new problem. Assessment and plan included will check for influenza/COVID-19 due to confirmed cases at the facility. R13's laboratory (lab) result fax transmission form dated 4/12/25, included the result for an influenza A test ordered by NP-A. The swab for the test was collected on 4/10/25 at 11:00 a.m. and the test resulted on 4/11/25 at 9:58 p.m. The influenza A value was listed as detected (A) with a legend identifying A to mean abnormal. R13's late entry progress note dated 4/10/25, identified it was entered on 4/15/25 by nurse manager registered nurse (RN)-A. The note indicated a swab was collected from R13 on 4/10/25 to test for influenza, RSV, and COVID-19 and lab results came out negative.…
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 · D2025-04-24 · 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
Based on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R5) reviewed for documentation. Findings include: R5's facesheet indicated her current admission to the facility began on 7/6/23 with most recent return to the facility date of 4/18/25. R5's progress note dated 4/9/25, indicated R5 was confused, slow to respond, very weak, showed signs of distress, and was sent to the hospital. R5's progress note dated 4/18/25, indicated R5 was re-admitted to the facility from the hospital at 1:26 p.m. via emergency medical services. R5's electronic health record (EHR) reviewed on 4/22/25, did not include NP-A's visit note dated 4/9/25 nor a hospital discharge summary or physician history and physical (H&P) from R5's hospitalization 4/9/25 to 4/18/25. During an interview on 4/22/25 at 12:32 p.m., health unit coordinator (HUC)-A stated provider visit notes typically came in the same day as the visit or the next day.…
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 · E2025-04-02 · tag F0554 — patternAllow 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 appropriately complete a thorough self administration assessment on 3 of 4 (R2, R3 and R4) sampled residents (who preferred not to administer their own medication) by ensuring residents who were left while the administration was occurring unattended, were found competent to leave their masks and/on or turn off the nebulizer appropriately when finished. Findings include: R2's quarterly minimum date set (MDS) dated [DATE] indicated intact cognition with diagnoses including multiple sclerosis and asthma. R2's SAM dated 3/21/25 indicated R2 did not want to self-administer medications. No further assessment occurred to ensure R2 could successfully complete treatment if left unattended. On 4/1/2025 at 1:15 p.m., R2 was observed sitting in her wheelchair with a nebulizer mask applied on her face with the nebulizer machine turned on. No staff members are observed in the room or in the hallway outside the room. On 4/2/2025 11:13 a.m., R2 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 comprehensively assess and discuss risks and benefits prior to installation of grab bars for 1 of 1 residents (R194) observed to have grab bars affixed to their bed. Findings include: R194's admission Minimum Data Set (MDS) indicated he had moderate cognitive impairment and required partial to moderate staff assistance with bed mobility. R194's Care Area Assessment (CAA) for cognitive loss and dementia dated 11/19/24, indicated he had observable confusion, disorientation, and forgetfulness. The CAA indicated R194 was alert and able to make his needs known. R194's CAA for falls dated 11/19/24, indicated he was a fall risk and identified risk factors including hearing impairment, cognitive impairment, pain, impaired mobility and balance, history of two falls prior to admission, and weakness post-hospitalization. A device-equipment assessment dated [DATE], indicated a left and right upper assist rail/grab bar were used. The assessment…
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 before2024-11-21 · 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 enhanced barrier precautions (EBP) were followed and appropriate personal protective equipment (PPE) was worn as required during high contact care for 2 of 3 residents (R193, R9) who required EBP and were reviewed for infection control. Findings include: R193's Minimum Data Set (MDS) dated [DATE], identified he had mild cognitive impairment and required partial-to-moderate staff assistance with toileting and personal hygiene. The MDS further indicated R193 had a bladder catheter. R193's Diagnoses Report printed 11/22/24, listed his diagnoses of bladder cancer that spread to his bone tissue, muscle weakness, malnutrition, diabetes, urinary tract infection (UTI), and artificial openings of urinary tract status-bilateral nephrostomy (nephrostomy tubes, or surgically placed catheter tubes that drain urine directly from the kidneys outside of the body into collection bags). R193's current physician orders printed 11/22/24 were reviewed…
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 14 citations
- Potential for harm · E2024-06-26 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 identify the preference for health care directives for seven of ten residents (R1, R2, R3, R4, R6, R7, and R10) reviewed for advanced directives. Findings include: R1's face sheet printed on 6/25/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis. Additional diagnoses included acute diastolic heart failure, acute embolism, thrombosis of unspecified deep veins of proximal lower extremities, acute respiratory failure with hypoxia, encephalopathy, neoplasm of uncertain behavior of meninges, and chronic systolic heart failure. R1's face sheet indicated R1 was the responsible party. R1's care plan printed 6/25/24 indicated R1 had cognitive loss/dementia. R1's brief interview for mental status (BIMS) assessment completed 6/4/24 indicated R1 had a score of 13, which indicated R1 had severe cognitive impairment. R1's care conference completed on 6/13/24 indicated R1 did not have any type of advance directive. 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 · E2024-06-26 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 could not ensure staff were properly trained in basic life support (BLS) including cardiopulmonary resuscitation (CPR) to provide BLS/CPR to residents requiring such care for 18 of 62 licensed staff records registered nurse(RN)-A, RN-B, RN-C, RN-D, RN-E, RN-F, RN-G, RN-H, RN-L, licensed practical nurse (LPN)-A, LPN-B, LPN-C, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H, and LPN-I) when reviewed for BLS/CPR training. The facility contacted licensed staff for proof of BLS/CPR Certification and obtained five more staff BLS/CPR certifications. Findings include: The facility provided a BLS/CPR book for staff who have a BLS/CPR certification. The book was reviewed and did not contain BLS/CPR certificates for RN-A, RN-B, RN-C, RN-D, RN-E, RN-F, RN-G, RN-H, RN-L, LPN-B, LPN-C, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H, and LPN-I. LPN-A's certification was expired. LPN-A's personnel record was reviewed. LPN-A's BLS certificate indicated LPN-A took an online course on [DATE] without…
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 · D2024-04-18 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 resident bathing preferences were honored for 1 of 2 residents (R3) who voiced concerns about bathing routines. Findings include: R3's undated facesheet indicated R3 was admitted to the facility in March 2024 with diagnoses including fractures with subsequent surgery of the left ankle and right ankle and foot, dislocated joint in right foot, osteoarthritis, and pain. R3's Minimum Data Set (MDS) dated [DATE], indicated R3 had intact cognition, was able to make himself understood and understand others, did not exhibit rejection of cares, had functional limitation in range of motion in both lower extremities, was dependent on staff for showering/bathing, required substantial assistance with personal hygiene, and R3's transfer status for getting in/out of a tub/shower was not assessed due to medical condition or safety concerns. R3's bathing, dressing, and grooming care plan dated 3/7/24, noted R3 required assistance and included R3…
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 · D2024-04-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to revise a comprehensive care plan for 1 of 3 residents reviewed (R3) for services provided per plan of care. Findings include: R3's undated facesheet indicated R3 was admitted to the facility on [DATE] with diagnoses including nondisplaced trimalleolar fracture of left lower leg (left ankle fractured in three places) with open reduction and internal fixation (ORIF, a surgery to stabilize and heal broken bones), nondisplaced fracture of medial malleolus of right tibia (right ankle fracture) with ORIF, dislocation of tarsometatarsal joint of right foot Lisfranc injury (dislocation of joint in right foot), fracture of unspecified metatarsal bones on right foot with ORIF, acute and chronic respiratory failure, type 2 diabetes, osteoarthritis, vitamin deficiency, and pain. R3's provider note dated 3/7/24, indicated R3 was admitted from a hospital after bilateral extensive ankle surgery on 2/23/24 and would have follow-up with podiatry. R3'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.
- Potential for harm · Dcited before2024-04-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 document review, the facility failed to ensure adequate supply and administration of ordered medications for 1 of 1 resident (R1) reviewed for pharmacy services. Findings include: R1's facesheet dated 4/16/24, indicated R1 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of hepatic flexure (colon cancer), enterocutaneous fistula of intestine (abnormal opening connecting intestines through to the skin), colostomy, bilious (bile) vomiting, nausea, gastro-esophageal reflux disease, presbyesophagus (abnormally shaped esophagus), pharyngoesophageal phase dysphagia (difficulty swallowing), anemia, and vitamin deficiency. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 received parenteral/IV (intravenous) feeding (nutrition provided through a vein instead of orally) of 51% or more of R1's total calories and 501 cubic centimeters (cc) or more daily fluid intake while a resident. R1's physician orders included an order with start date 2/7/24 and end date…
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 · Fcited before2023-10-05 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 INFECTIOUS DISEASE SURVEILLANCE Based on observation, interview, and document review, the facility failed to implement an ongoing surveillance program for infectious disease tracking of new admissions that could affect all 90 residents and all staff at the facility, ensured hand hygiene and infection control was completed for 2 of 3 resident (R27 & R46) observed for incontinent cares and hand hygiene was completed during catheter cares to minimal risk of infection for 1of 1 residents (R27) reviewed for infection control practices. During an interview on 10/4/23 at 12:33 p.m., the facility infection preventionist (IP) stated the facility conducts infection surveillance for tracking and trending infections via spreadsheets. The IP further stated that the facility does not keep track of the active infections of new admissions, only the residents that develop an infection while residing at the facility. Review of monthly facility infection surveillance spreadsheets from January 2023 through September 2023 lacked…
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 · D2023-10-05 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), was not provided to 1 of 3 residents (R111) who continued to reside in the facility upon termination of Medicare A benefits. Findings include: R111's SNFABN was requested but not received. Documentation review found R111's Notice of Medicare Non-Coverage (NOMNC) benefits were set to end 09/22/2023. R111 was made aware of this on 09/22/2023. R111's guardian was made aware of this via telephone on 09/20/2023. In neither instance, the SNFABN was not presented. Review of R111's electronic medical chart (EMR) confirmed that there was no documentation to contact R111's representative/guardian regarding the SNFABN. On 10/03/2023 at 02:21 p.m., Social worker (SS)-C stated R111 did not have a SNFABN due to being in foster care. SS-C stated communication with family representative was via email, as R111 doesn't really talk. SS-C confirmed that SNFABN was not presented. Continued conversation with (SS)-C identified that there had been a facility staff…
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 · D2023-10-05 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 level I Pre-admission Screening and Resident Review (PASRR) level I was completed and accurate prior to admission to the facility for 2 of 3 residents (R2, R22) reviewed for pre-admission screening (PAS). Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was moderately cognitively impaired and had diagnoses of dementia, anxiety disorder, depression, and psychotic disorder. R2's Initial Pre-admission Screening assessment and corresponding letter from Senior LinkAge Line dated 7/13/18, indicated Senior LinkAge Line did not complete the PAS and forwarded the request to the county for completion. R2's medical record lacked evidence a level I PAS was completed prior to admission to the facility. R22's quarterly MDS dated [DATE], indicated he was moderately cognitively impaired, and had diagnoses of seizure disorder and depression. R22's medical record lacked evidence a level I PAS was completed prior to admission…
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 · D2023-10-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide oral care for 1 of 1 residents (R14) reviewed for activities of daily living for dependant residents. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 was moderately cognitively impaired, required assistance of one staff for oral care, had diagnoses of cerebral palsy, Parkinson's disease, lung disease, and received hospice services. The MDS indicated he did not refuse cares. R14's care plan dated 12/20/19, indicated R14 had his own teeth and required set-up assistance and assist of one staff as needed for oral care. R14's dental Chart Progress Note dated 9/15/23, indicated he was at high risk for caries (cavities) and had an application of a decay-arresting product. He had moderate generalized gingivitis, tooth decay, moderate plaque, and should brush his teeth for two minutes twice daily focusing on the gumline. R14's Point of Care History identified R14 was dependent on staff for oral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 catheter care and maintenance to reduce the risk of urinary tract infections (UTIs) for 2 of 2 (R27, R75) residents reviewed for catheters. Findings include: R75's admission Minimum Data Set (MDS) dated [DATE], indicated R75 was cognitively intact, required extensive physical assistance with most activities of daily living (ADL), and had an indwelling urinary catheter. R75's diagnoses included hemiplegia/hemiparesis (one sided weakness/paralysis) following cerebral infarction (stroke) affecting left non-dominant side, retention of urine, and acute kidney failure. R75's indwelling catheter care plan (CP) last reviewed 9/20/23, indicated R75 required and indwelling catheter related to urinary retention with a goal resident will not exhibiting [sic] signs of urinary tract infection. The CP instructed staff to monitor urinary output every shift and provide catheter care twice a day and as needed. R75's resident profile…
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 before2023-10-05 · 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 administer oxygen in accordance with the provider orders for 1 of 1 residents (R14) reviewed for respiratory care. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 was moderately cognitively impaired, had diagnoses of lung disease, cerebral palsy, and Parkinson's disease, and was on hospice. The MDS did not indicate R14 used oxygen (O2) therapy. R14's care plan dated 12/20/19 included administer oxygen at 1 to 4 LPM via nasal cannula to keep sats (saturation - blood oxygenation level) greater than 89 percent. R14's Physician Order Report dated 10/4/23, included the following: - Continuous oxygen at 2 liters per minute (LPM) per nasal cannula unless resident requests not to wear starting 4/23/13, discontinued 9/25/23. - Continuous oxygen at 3 LPM per nasal cannula unless resident requests not to wear starting 9/25/23. - Nurse ensure oxygen is 2 liters after giving 1:00 p.m. Ativan (antianxiety…
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 before2023-10-05 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 assess the resident for risk of entrapment, review risks and benefits of bed rails with the resident or their representative, and obtain informed consent for 1 of 1 residents (R21) reviewed for bilaterial grab bars on their bed. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment and no rejection of cares. R21 required extensive assistance with 1 to 2 persons with bed mobility, transfers, dressing, and toilet use. R21's diagnoses included hemiplegia or hemiparesis (complete or partial loss of muscle function on one side of the body) and seizure disorder or epilepsy (sudden, uncontrolled burst of electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness). R21's care plan problem dated 2/29/16, identified 21's potential decline in ability to participate in bed mobility. R21's bed…
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 before2023-09-19 · 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 delayed the necessary care and treatment to manage symptoms of pain, anxiety, and agitation for 1 of 3 residents (R2) reviewed for quality of care. R2 was restless, yelling out for help, and not provided the prescribed medications to alleviate discomfort. R2's care plan dated 7/14/23, indicated R2 required staff to monitor her degenerative joint disease (inflammation and joint damage) and if the condition worsened to update her medical providers for additional medication. R2's care plan dated 7/17/23, indicated she was alert, oriented, and able to make her needs known. The planned intervention was to update her medical provider if she developed worsening symptoms not resolved by the current treatment plan. R2's Minimum Data Set (MDS) dated [DATE], indicated she had mild impaired cognition, a minimum depression score, and no behavioral symptoms. She had a stroke and was unable to move her left side, heart disease, arthritis, difficulty sleeping, restlessness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-12-04 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure results of complaint investigations were available for review. This had the potential to affect all 83 residents residing in the facility, as well as family, visitors, and staff.Findings include:During observation on 12/2/25 at 11:30 a.m., a review was completed of the facility survey results, located in the in a three ring binder labeled Survey Results, located in the file holder, next to the reception desk, at the entrance of the building. The survey results posted included the recertification survey results from the past three recertification surveys however, lacked all 2567's (reports completed by surveyors which include the findings of survey investigations and the plan of correction developed by the facility) regarding complaint investigations.A review of the surveys completed within iQIES (internet Quality Improvement and Evaluation System-an online computerized federal document site which contains the surveys completed for facilities which includes both recertification surveys and complaint…
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
$17,345 in federal fines across 1 penalty.
- $17,345 — penalty dated 2025-04-24
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 CASSIA — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 3.7 | -0.7 vs chain |
| Staffing | 5 of 5 | 4.8 | +0.2 vs chain |
| Quality measures | 3 of 5 | 4.3 | -1.3 vs chain |
The other 15 homes this chain runs (chain average 4.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AUGUSTANA CARE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2018 |
| CASSIA | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2018 |
| ELLINGSON, ERIK | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| MORRIS, CYNTHIA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| NYE, GERALD | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| PARKS, CHARLES | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| RAMSDALE, SCOTT | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| VERLAUTZ, MICHELENE | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| BRADY, JAIME | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2025 |
| BROWN, ANGELA | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2018 |
| KERN, MATTHEW | Individual | CORPORATE OFFICER | — | since 01/01/2018 |
| LIBBON, PAUL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2025 |
| MASON, KRISSA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2025 |
| STADTHERR, SEELOCHANI | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2018 |
| YOUNGQUIST, KATHRYN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2018 |
| DAVENPORT, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/09/2025 |
| HEYRMAN, TARA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/12/2022 |
| KLEIN, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/03/2022 |
| KUKA, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2018 |
| MITTAL, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2025 |
| MOORE, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2018 |
| PAHL, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/15/2026 |
| SAIBOU, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2018 |
CMS files one row per role, so the 38 rows in the source record cover these 23 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.
This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 245493. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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 →
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