Good Samaritan Society - International Falls
2201 Keenan Drive, International Falls, MN 56649 · Non profit - Corporation · 54 certified beds · (218) 283-8313 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- 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 $8,190 in federal fines (most recent 2024-01-19)
- its payroll-based staffing score sits well above its independent inspection score
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 | 23.4% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.1% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.7% | 4.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.6% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.0% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.2% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.0% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 58.6% | 82.7% | 79.4% | worse |
‡ 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.
31.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 31.9%CMS range 22.0–45.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 5.7–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 54 beds and averages 50.9 residents a day — about 94% occupied, or roughly 3 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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 4.38 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.29 to 0.55 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure adequate supervision to reduce the risk of falls for 1 of 3 residents (R1) who had a history of falls with serious injury. This resulted in actual harm for R1 who fell and sustained a laceration to her head and a subdural hematoma (pool of blood between the brain and its outermost covering). In addition, the facility failed to develop a sustainable plan for ongoing supervision. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she was dependent on staff for transfers. The MDS indicated R1 did not have a fall since the prior assessment. R1's care plan dated 10/29/23, identified a communication problem related to dementia and a self care deficit. The care plan indicated R1 used a wheel chair with assistance from staff for locomotion and transferred using a mechanical lift. The care plan indicated R1 had a fall on 12/19/23, resulting in a subdural bleed. The care plan…
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 before2026-01-14 · 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 ensure shaving preferences were assessed and provided for 1 of 5 residents (R8) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include:R8's annual Minimum Data Set MDS dated [DATE], identified R8 had severe cognitive impairment and diagnoses that included dementia. R8 required substantial/maximal assistance for personal hygiene.R8's medical record lacked evidence his shaving preferences were assessed.R8's care plan revised 12/2/25, identified R8 had an ADL self-care performance deficit related to right shoulder pain, dementia, and a traumatic brain injury exhibited by need for assist with ADL's. The care plan directed staff R8 required assist of one staff to complete personal hygiene. However, the care plan failed to address R8's shaving preferences.During an observation on 1/13/26 at 8:58 a.m., R8 was up, dressed for the day and sitting in his wheelchair at a table in the dining…
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 · D2026-01-14 · 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 primary care provider of an abnormal laboratory result for 1 of 5 residents (R4) reviewed for unnecessary medications.Findings include: R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact and required maximal assistance with dressing and moderate assistance with toileting, grooming and transfers. Diagnoses included atrial fibrillation (irregular heartbeat), anemia, depression, long term use of anticoagulants and dysphagia (difficulty swallowing). P4's Elder Care 60 Day Regulatory Visit dated 11/17/25, identified P4 was being seen for regular routine rounds with orders to draw yearly comprehensive blood count with differential (CBC), basic metabolic panel (BMP), thyroid stimulating hormone (TSH). prothrombin time (PTT) and a ferritin level (which indicated the amount of iron stored in the body). P4's medical record lacked documentation of lab work drawn, or results of any blood…
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 before2026-01-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was provided following personal cares for 2 of 5 residents (R5, R8) observed during the provision of activities of daily living (ADLs).Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had severe cognitive impairment with a diagnosis of dementia. R8 required substantial/maximal assistance for personal hygiene.R8's care plan revised 12/2/25, identified R8 had an ADL self-care performance deficit related to right shoulder pain, dementia, and traumatic brain injury exhibited by the need for assist with ADL's. R8 required assist of one staff for personal hygiene. R8 required stand aide with assist of 1 and a riser on the toilet for toileting. R5's quarterly (MDS) dated [DATE], identified R5 was cognitively aware and had diagnoses that included hemiplegia and hemiparesis (left sided weakness). R5 required substantial/maximal assistance with toileting.R5's care plan revised 7/27/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-11-25 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 review and update the facility assessment to incorporate the minimal staff requirements; and all resources and conditions to care for the resident populations. This had the potential to affect all 50 residents who resided in the facility. Findings include: The Facility assessment dated [DATE], identified the need to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment listed resident count, activities of daily living (ADL) assistance needed, behavioral symptoms and active diagnoses. The facility utilized an interdisciplinary approach to meet the needs of residents across all shifts, including nights and weekends. The scheduler would check the schedule and divide staff based on the acuity of the facility assessment. The facility assessment failed to include information on the staffing levels needed for specific shifts, such as day, evening, and nights based 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.
- Potential for harm · F2024-11-25 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to develop action plans for identified areas of monitoring and failed to identify and implement at least one process improvement project (PIP) This had the potential to affect all 50 residents who resided in the facility. Findings include: The Quality Assurance, Action Committee Meeting Minutes dated 7/11/24, identified the team had reviewed the following topics: -infection control. -emergency operation plan and facility assessment. -dietary concerns -therapy staffing changes -documentation of assessments and coding -resident council complaints -life style enrichment -human resources -life safety and environment The data failed to identify any facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality Assurance, Action Committee Meeting Minutes dated 8/22/24, identified the team had reviewed the following topics: -nursing services -resident council complaints -safety and emergency preparedness -employee action committee results -financial stewardship, -action plans from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-25 · 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 develop and implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting infections and communicable disease along with a monthly analysis; and failed to conduct COVID-19 testing of staff and residents per Centers for Disease Control (CDC) guidelines. In addition, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R205) reviewed with pressure ulcers; and failed to wear a mask during a peripherally inserted central catheter (PIIC) line dressing change for 1 of 1 resident (R206) reviewed with a PIIC. These deficient practices had the potential to affect all 50 residents residing in the facility. Findings include: Surveillance and Analysis: The Monthly Report of Resident Infections in Location dated August 2024, identified unit, resident name, room number, admit date , infection type, body system, criteria met yes or no, onset C (community) or F (facility),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure an electric wheelchair was maintained in working order for 1 of 1 resident (R23) reviewed for accommodation of needs. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified R23 had intact cognition and used a motorized wheelchair. R23 was independent with mobility once seated in his motorized wheelchair. Diagnoses included paraplegia, dependence on wheelchair and autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system). R23's care plan dated 3/15/24, identified R23 had limited physical mobility related to paraplegia from spinal cord injuries and weakness evidenced by R23's need for specialty wheelchair. The goal was for R23 to remain independent with locomotion in the facility. Interventions included use of motorized wheelchair in the facility. On 11/19/24, R23 was lying in bed watching television. A manual high back wheelchair was stored in the shower area of…
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 before2024-11-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 1 of 5 residents (R27) reviewed for unnecessary medications. Findings include: R27's quarterly MDS dated [DATE], identified R27 had severe cognitive impairment. Diagnoses included Alzheimer's, non-Alzheimer's dementia, diabetes, and depression. The MDS identified R27 received an antianxiety medication. R27 medication administration report (MAR) for the month of October 2024, identified R27 received Trazodone (an antidepressant) for generalized anxiety disorder, restlessness, and agitation. The MAR/orders did not identify R27 was receiving an antianxiety medication during the MDS lookback period. During an interview on 11/25/24 at 3:14 p.m., registered nurse (RN)-B identified she did the most recent MDS for R27. When RN-B went over the medications for R27, RN-B reviewed medications by what they were used for and not specifically the class of medication. R27's was receiving an…
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 before2024-11-25 · 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 assistance with toileting for 1 of 1 resident (R203) reviewed for activities of daily living and who were dependent on staff for their care. Findings include: R203's admission Minimum Data Set (MDS) dated [DATE], identified R203 had severe cognitive impairment and did not have behaviors. R203 required partial to moderate assistance with eating. R203 was dependent with toileting and transfers and was always incontinent of bowel and bladder. Diagnoses included malignant neoplasm of the sinus and brain, palliative care, moderate protein-calorie malnutrition, and pressure ulcer stage two of the sacral region. R203's care plan dated 10/31/24, identified R203 was dependent with most activities of daily living and was bedfast all or most of the time. R203 was incontinent of bowel and bladder. Staff were directed to check and change every two hours and as needed. During continuous observation on 11/20/24 from 4:30 p.m. to 7:10 p.m., R203…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely repositioning for 1 of 1 resident (R203) reviewed for pressure ulcers. Findings include: R203's admission Minimum Data Set (MDS) dated [DATE], identified R203 had severe cognitive impairment and did not have identified behaviors. R203 required substantial to maximum assistance with rolling side to side and sitting up. R203 was dependent with toileting and transfers and was always incontinent of bowel and bladder. R203 was at risk for pressure ulcer development and was admitted with a stage two unhealed pressure ulcer. A turn and reposition program was in place as well as a pressure reducing device for R203's bed. Diagnoses included malignant neoplasm of the sinus and brain, palliative care, moderate protein-calorie malnutrition, and pressure ulcer stage two of the sacral region. R203's care plan dated 10/31/24, identified R203 was dependent with most activities of daily living and was bedfast all or most of the time. R203…
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 19 citations
- Potential for harm · Dcited before2024-11-25 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 comprehensively assess for trauma informed care to identify potential triggers and avoid potential re-traumatization for 1 of 1 resident (R22) reviewed who had a history of trauma. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behavior of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing and wandering, one to three times per week. R22 also rejected care four to six times weekly. Diagnoses included chronic myeloid leukemia, anxiety, post traumatic stress disorder (PTSD) and dementia. R22's care plan with last revision date 10/11/24, identified R22 had impaired cognition and impaired thought process as well as behavior symptoms of hitting staff, name calling, throwing objects, sexual comments and unpredictable behaviors related to impaired cognition, anxiety and PTSD. Interventions included approach with soft…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified and communicated to the facility the need for monitoring for potential adverse events for high- risk medications for 2 of 5 residents (R22, R37); and failed to identify the need to monitor for adverse behaviors for psychotropic medications for 1 of 5 residents (R37) reviewed for unnecessary medications. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behavior of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing, and wandering, one to three times per week. R22 also rejected care four to six times weekly. The MDS identified R22 had received antidepressant medications daily. Diagnoses included chronic myeloid leukemia, anxiety, post-traumatic stress disorder (PTSD) and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 ensure adverse event monitoring was completed for high-risk medications 2 of 5 residents (R22, R37) reviewed for unnecessary medications. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment. Diagnoses included chronic myeloid leukemia and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered medications and treatments at the nursing home. These included orders for: Gleevec (to treat myeloid leukemia) 400 milligrams (mg) daily, nurse to monitor for side effects and notify MD as needed. The summary listed an order which directed Nurse to monitor for the following symptoms: weakness, dizziness, sudden changes in strength or mobility, nausea or vomiting, unusual bleeding, bruising, black or tarry stools, extreme fatigue. Swelling, redness and/or pain in upper or lower extremities, yellowing of the skin or eyes, swelling of the face, mouth, tongue,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure adverse event monitoring was completed for 2 of 5 residents (R22, R37); and failed to monitor adverse behaviors for 1 of 5 residents (R37) reviewed for unnecessary medication use and were taking a psychotropic medication. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behaviors of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing and wandering, one to three times per week. R22 also rejected care four to six times weekly. The MDS identified R22 had received antidepressant medications daily. Diagnoses included chronic myeloid leukemia, anxiety, post-traumatic stress disorder (PTSD) and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered medications and treatments at the nursing home. These included orders for: venlafaxine (to treat depression) 75 mg daily. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure two insulin pens were labeled with the resident name for 1 of 1 resident (R154) observed to receive insulin. Findings include: R154's admission Record dated 11/25/24, identified R154 was admitted to the facility on [DATE]. R154's Diagnosis Report dated 11/25/24, identified R154 was a Type 2 diabetic. R154's Order Summary Report dated 11/25/24, identified the following: 11/13/24, R154 was prescribed insulin lispro (Humalog) (a short acting insulin) with the following instructions: - insulin lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/milliliter (ml) Inject as per sliding scale: if 0 - 160 = 0 UNITS; 161 - 190 = 1 UNIT; 191 - 220 = 2 UNITS; 221 - 250 = 3 UNITS; 251 - 280 = 4 UNITS; 281 - 310 = 5 UNITS; 311 - 340 = 6 UNITS; 341 - 370 = 7 UNITS; 371 - 400 = 8 UNITS; 401 - 999 = 9 UNITS, subcutaneously three times a day for Type 2 diabetes. Give sliding scale dose in addition to scheduled dose. - Insulin Lispro (1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-25 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 establish a process for antibiotic review in order to determine appropriate indications for use of an antibiotic for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had diagnoses that included renal insufficiency, diabetes, Alzheimer's disease, and dementia. R15 was always continent of bowel and bladder and required supervision or touching assistance with personal hygiene. The Monthly Report of Resident Infections in Location dated November 2024, identified R15 had a urinary tract infection with an onset date of 11/2/24. Symptoms included gross hematuria and flank pain related to kidney stones. However, the report failed to identify if R15 was treated with an antibiotic and/or if a urinalysis or urine culture were obtained. R15's Order Summary Report dated 11/2/24, identified R15's was prescribed cefdinir (an antibiotic) 300 mg capsules give 1 capsule by mouth 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.
- Potential for harm · F2023-10-19 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
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 resident [NAME] of Rights were provided verbally and ongoing for residents of the facility for 2 of 2 residents (R22, R43) interviewed during resident meeting. This deficient practice had the potential to affect all 48 residents residing in the facility. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had no cognitive impairment. R43's quarterly MDS dated [DATE], identified R43 had no cognitive impairment. During an interview on 10/17/23 at 1:03 p.m., R22 and R43 stated they did not know what the Residents' [NAME] of Rights was. R22 thought she received a paper when she was admitted to the facility, and possibly had it in a drawer in her room. R43 did not recall ever receiving anything about it. Neither recalled a resident council meeting where the [NAME] of Rights was discussed either. During an interview on 10/18/23 at 8:08 a.m., social services designee (SSD) stated she conducted the resident…
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 · Ecited before2023-10-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure laundry services were conducted in a manner to promote sanitary conditions. This had the potential to affect all residents who ultilized bedspreads. Findings include: On 10/17/23 at 8:55 a.m., a jumbled pile of bedspreads was piled onto a rolling office chair with the edges of the bedding touching the floor. Housekeeping (HSKG)-A stated the bedspreades were left that way the evening prior and would need to be re-washed. HSKG-A was not the normal laundry staff member and was covering for the day. On 10/17/23 at 5:27 p.m., The jumbled pile of bedspreads remained on the rolling office chair, and several had fallen onto the floor. HSKG-A stated the last load of linens for the day were being folded and would be delivered to the units for use. HSKG-A stated I'll just be honest. If you hadn't walked in, I would have just folded them [the bedspreads] and put them in the cupboard, but I'll rewash them now. During an interview on 10/18/23 at 3:17 p.m., the director of nursing (DON) stated she expected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R4, R5, R21, R29) reviewed for immunizations. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was admitted to the facility on [DATE], was [AGE] years old and had a diagnosis of Alzheimer's disease. R4's Immunization Report dated 10/19/23, identified R4 received a pneumococcal polysaccharide vaccine (PPSV23) on 11/27/13. R4's medical record did not include evidence R4 or R4's representative received education regarding pneumococcal vaccine booster and there was no indication R4 was offered the pneumococcal vaccine per CDC guidance. R5's quarterly MDS dated [DATE], identified R5 was admitted to the facility on [DATE], was [AGE] years old and had a diagnosis of diabetes. R5's Immunization reported dated 10/19/23, identified R5 received a PPSV23 on 3/5/18, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0623 — isolatedProvide 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 ensure the long term care ombudsman was notified of facility initiated transfers for 1 of 2 residents (R7) reviewed for hospitalization. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R7's progress notes identified the following: - 9/10/23, R7 was transferred and admitted to the hospital for illness. - 9/12/23, R7 was readmitted following transfer on 9/10/23. - 9/22/23, R7 was transferred to the hospital for illness on 9/18/23 and returned on 9/22/23. R7's medical record lacked evidence notification was sent to the state ombudsman's office regarding the transfers to the hospital. During an interview on 10/18/23 at 2:08 p.m., the director of nursing (DON) stated the process for notifying the state ombudsman was the responsibility of the social services designee (SS)-A and would expect the notification to be done in the required time frame. During an interview on 10/19/23 at 10:45…
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 · D2023-10-19 · tag F0625 — isolatedNotify 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 the resident/responsible party a written bed hold policy at the time of hospital transfer for 1 of 1 residents (R7) who was reviewed for hospitalization. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R7's progress notes identified the following: - 9/10/23, R7 was transferred and admitted to the hospital for illness. - 9/12/23, R7 was readmitted following transfer on 9/10/23. - 9/22/23, R7 was transferred to the hospital for illness on 9/18/23 and returned on 9/22/23. R7's medical record lacked evidence a bed hold was provided at the time of transfer for either hospitalization. During an interview on 10/16/23 at 2:35 p.m., R7 stated she was hospitalized twice in September 2023, and did not recall receiving a notification of bed hold when she was transferred. During an interview on 10/18/23 at 1:57 p.m., the household coordinator (HC) for Voyageur's Haven unit stated she 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 before2023-10-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for 1 of 2 residents (R31) reviewed for accident hazards. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had moderately intact cognition and a diagnosis of Parkinson's disease. R31 needed limited assistance with bed mobility and transfers. R31's undated, care plan identified R31 was independent with a grab bar on one side of the bed. On 10/16/23 at 2:27 p.m., R31's bed and grab bar were observed. There was a space of about four to five inches between the mattress and the grab bar of R31's bed. On 10/18/23 at 9:58 a.m., the maintenance director (MD) measured five inches in the space between the mattress and grab bar. The MD stated he didn't do any kind of measuring with the bed rails and either the director of nurses (DON) or a nurse manager would know about bed rail safety, he didn't know what the measurements should be. During an interview on 10/18/23…
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 · D2023-10-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 ongoing monitoring of weight for nutrition status was implemented as directed for 2 of 2 residents (R2, R21) reviewed fro nutrition. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had a severe cognitive impairment and diagnoses included stage 3 pressure ulcer, muscle weakness, and hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. R2 was dependent upon staff for all care areas and had no known weight loss. R2's care plan undated, identified R2 had a potential for alternation in nutrition related to diagnosis and history of losing weight. R2 had a healing pressure ulcer. The care plan lacked to identify R2's weight data collection R2's Medication Review Report dated 1/24/23, identified R2 received a high-calorie shake three times a day wiht meals and as needed if unable to eat/refusal to eat meal. The report lacked to identify staff were directed to obtain R2's weight. Dietitican…
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 before2023-10-19 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 comprehensively assess for trauma informed care to identify potential triggers and avoid potential re-traumatization for 1 of 1 resident (R5) reviewed who had a history of trauma. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and diagnoses included post-traumatic stress disorder (PTSD) cerebral palsy, anxiety and depression. R5 exhibited rejection of care, verbal behavioral symptoms directed towards other such as threatening others, screaming at others and/or cursing at others, and behavioral symptoms not directed toward others such as hitting or scratching self, pacing, and/or verbal/vocal symptoms such as screaming or disruptive sounds. R5's Trauma assessment dated [DATE], identified R5 never experienced some form of trauma or a stressful event. The assessment failed to identify R5 had a diagnosis of PTSD. R5's care plan revised 9/8/23, identified R5 had a behavior symptom…
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 · D2023-10-19 · 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 obtain informed consent, prior to resident use of bed rails for 1 of 2 residents (R31) reviewed for bed rail use. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had moderately intact cognition and a diagnosis of Parkinson's disease. R31 needed limited assistance with bed mobility and transfers. R31's undated care plan identified R31 was independent with a grab bar on one side of the bed. R31's medical record lacked an assessment for bed rail alternatives, entrapment risk, or informed consent for bed rail use. On 10/16/23 at 2:27 p.m., R31's bed was observed and there was a grab bar attached to the bed. During an interview on 10/18/23 at 10:10 a.m., the director of nurses (DON) stated the usual process on admission was that an assessment was done, and physical therapy was involved, to see if they can or should use a bed rail. The DON confirmed there was not informed consent…
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 · D2023-10-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety in 3 of 3 unit kitchenettes. This practice had the potential to affect all residents consuming food at the facility. Findings include: During an observation on 10/19/23 at 9:11 a.m., the resident refrigerator on the [NAME] unit had dried streaks of a white substance and fingerprints covering both fridge doors and freezer drawer. The freezer had an open container of Lactaid ice cream, and a container of [NAME] ice cream without names or opened-on dates. The fridge contained a plastic container covered with plastic wrap, labeled goulash with no resident name or opened-on date. During an interview on 10/19/23 at 9:17 a.m., dietary aid (DA)-C on the [NAME] unit confirmed the outside of fridge had dried streaks of a white substance and fingerprints covering both fridge doors and freezer drawer. DA-C stated they were supposed to clean the unit kitchens 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.
- Potential for harm · D2023-10-19 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program 1 of 2 residents (R31) reviewed for bed rail safety. Findings include: On 10/16/23 at 2:27 p.m., R31's bed was observed and there was a grab bar attached to the bed. There was a space of about four to five inches between the mattress and the grab bar of R31's bed. During an interview on 10/18/23 at 9:58 a.m., the maintenance director (MD) stated he didn't do any kind of inspecting or measuring of beds or bed rails and didn't know what the measurements for bed safety should be. There wasn't a schedule for regularly inspecting beds, mattresses, or bed rails. During an interview on 10/18/23 at 10:10 a.m., the director of nursing (DON) stated environmental services installed the bed rails, but she was not sure if anyone was taking measurements for bed safety. During an interview on 10/19/23 at 10:14 a.m., the interim-administrator stated he was not sure what the process for inspection and maintenance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-11-25 · tag F0732 — widespreadPost nurse staffing information every day.
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 consistently post the census on the nurse staff posting; failed to identify when the posting changed due to call ins; and failed to retain the nurse staff posting for 18 months. This had the potential to affect all 50 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation on 11/19/24 at 7:09 a.m., the staff posting was in a display case at the front entrance at the persons in charge list. The posting was dated Friday 11/15/24, and identified the census was 51 and listed the following staff scheduled working hours per shift for each nursing job class. However, the posting failed to identify the staff actually worked hours due to call-ins, vacations and/or staff shortages. The facility provided a print out that reflected staff timecard punches, however, an actual working staff schedule that reflected call-ins, staff shortages and/or vacations was requested, but not received. The nurse staff postings dated 10/8/24 through 11/15/24, were…
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 · Bcited before2023-10-19 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 5 residents (R3, R40, R4, R25, R1) reviewed for restraints; and 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and included a diagnosis of multiple sclerosis. A bedrail as used as a restraint daily. R3's care plan revised 9/8/23, identified R3 had an activities of daily living (ADL) self-care performance deficit related to muscle wasting and atrophy and MS. R3 used bilateral bed rails to assist with bed mobility. R3's Physical Devise and/or Restraint Evaluation and Review dated 10/18/23, identified R3's bedrails would not be a restraint for R3. R3's Medication Review Report dated 10/19/23, identified grab bars were used for assisting in bed mobility. During an observation on 10/16/23 at 2:50 p.m., R3 was lying in bed with a grab bar on each side of the 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.
“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
$8,190 in federal fines across 1 penalty.
- $8,190 — penalty dated 2024-01-19
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 GOOD SAMARITAN SOCIETY — 92 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 | 3.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
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 |
|---|---|---|---|---|
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2019 |
| SANFORD | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 05/01/2026 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| COPEMAN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| SANDGREN, DEEANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2023 |
| SOLHEIM, PAIGE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| DTN STAFFING INC | Organization | ADP OF THE SNF | — | since 08/02/2024 |
| FOCUSONE SOLUTIONS | Organization | ADP OF THE SNF | — | since 03/04/2024 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/13/2018 |
| PHARMERICA CORPORATION | Organization | ADP OF THE SNF | — | since 02/01/2025 |
CMS files one row per role, so the 58 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 245318. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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.