La Crescent Health Services
101 South Hill Street, La Crescent, MN 55947 · For profit - Limited Liability company · 42 certified beds · (507) 895-4445 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 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 fell from 3 to 1 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 | 13.8% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.6% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.2% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.8% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.0% | 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 | 11.2% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.6% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.0% | 12.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 82.7% | 79.4% | better |
‡ 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.
57.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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 | 57.4%CMS range 44.7–70.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.2–15.1 | 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 | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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 | 0.91 | 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 42 beds and averages 30.3 residents a day — about 72% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.38 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.37 hrs/resident/day on weekends vs 4.05 on weekdays — 17% thinner on weekends. RN hours go from 1.56 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2026-04-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to prevent complications of enteral feeding and failed to provide appropriate treatment and services for 1 of 1 resident (R5) reviewed who required tube feedings and medication administration through a gastrostomy tube (g-tube). This failure created the likelihood of serious harm for R5, including worsening symptoms of nausea and vomiting, and additional hospital visits. The immediate jeopardy (IJ) began on 4/8/26 when the facility failed to follow professional standards of medication administration through a g-tube, pharmacy directions for medication administration, identify the symptoms and side effects of incorrectly using the g-tube. Subsequently, R5 experienced nausea and vomiting and was sent to the hospital with a diagnosis of pneumonia. The administrator and director of nursing (DON) were notified of the IJ on 4/9/26 at 6:17 p.m. The IJ was removed on 4/13/26 at 4:07 p.m., however, noncompliance remained at a lower scope 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 · E2026-04-14 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 served in a timely manner to preserve desired temperatures of food for 4 of 4 residents (R1, R10, R15, R30) reviewed who expressed concerns for food temperatures and palatability. This had the potential to affect all residents who consumed food from the facility kitchen. Findings include: On 4/8/26 at 1:34 p.m., an informal resident council meeting was held with R10, R15 and R30. The residents were asked, as part of the meeting, about bedtime snacks which prompted a conversation regarding food. R30 stated that she eats in the dining room for her meals and her food was frequently served cold. R30 stated this had been an issue for a long time and had talked to staff about this. R10 stated today my food was ice cold even with the cover on it. R10 stated the facility started putting covers on the food and it isn't helpful. R10 stated he eats his meals in the dining room, and his meals are almost always cold when they should…
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 · D2026-04-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess and care plan to ensure competency and safety with self-administration of medication for 1 of 1 resident (R20) observed to be self-administering medication in their room.Findings include: R20's quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, identified R20 had intact cognition. On 4/8/26 at approximately 7:20 a.m., R20 was observed sitting in her Broda chair (a type of positioning chair) in her room. R20 was administered her morning oral medications by registered nurse (RN)-A along with an inhaler after performing a respiratory assessment. RN-A prepared R20's nebulizer and placed the mask on R20's face. RN-A placed R20's call light pad on her lap and instructed her to turn her call light on when the treatment was completed. R20 stated she always puts the light on when she was finished with the treatment. On 4/8/26 at 7:52 a.m., assistant director of nursing (ADON) told RN-A that she had removed R20…
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 · D2026-04-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident representative/Power of Attorney (POA) about refusal of care and/or treatment for 1 of 1 resident (R5) reviewed for notification of changes.Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). During a record review, R5's dismissal summary from the 2/12/26 hospitalization; the hospital physician stated, R5 is unable to receive and evaluate information effectively 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 · D2026-04-14 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 1 resident (R15) reviewed for unnecessary medication use and who consumed antipsychotic medication.Findings include: Review of the 7/24/24, Olanzapine guidelines, located at: https://www.drugs.com/olanzapine.html#side-effects, identified olanzapine may cause serious side effects such as low blood pressure. Common side effects of olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or sitting position to standing). R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had no cognitive impairment and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS recorded R15 consumed antipsychotic, antidepressant, and 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 · D2026-04-14 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility to implement policies and procedures to ensure the State agency (SA) was notified in a timely manner for allegations of abuse for 1 of 1 residents (R32) whose allegations were reviewed.Findings include: R32's significant change in status Minimum Data Set (MDS) assessment, dated 1/24/26, identified R32 had moderately impaired cognition, required maximum staff assistance with dressing, moderate assistance with transfers and displayed no hallucinations, delusions, or rejection of care behaviors. R32's care plan, initiated on 6/20/23, identified R32 as a vulnerable adult at risk for potential abuse due to Alzheimer's disease and identified facility staff are education on reporting abuse and facility staff will follow facility policy and procedures. During an observation on 4/6/26 at 2:08 p.m., R32 was observed playing Bingo in the dining room with other residents and staff. At 3:36 p.m., R32 was observed sitting in her wheelchair in her room. R32 stated she couldn't remember how long she had been at the facility and directed 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 · D2026-04-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Office of the State Long-Term Cate (LTC) Ombudsman for 2 of 2 residents (R5 and R39) reviewed for hospitalizations and discharges. Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5's face sheet indicated R5 was originally admitted to the facility on [DATE]. R5 was hospitalized on [DATE] and 3/6/26. R5's Progress notes lacked any communication with the ombudsman after each hospitalization. Review of the notices to the Ombudsman, provided by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to develop and implement a person-centered care plan for 1 of 1 resident (R5) reviewed for comprehensive care plans.Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's hospital Discharge summary dated [DATE] noted the following:-Pressure injury to coccyx: red, blanchable: treatment offloading, barrier cream (Zinc, Petroleum) and open to air-Skin problem to left heel: clean,…
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 · D2026-04-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards of practice were followed during medication administration for 1 of 1 resident (R5) reviewed for gastrostomy tube (g-tube) medication administration.Findings include:According to the American Society for Parenteral and Enteral Nutrition article, Medication via Enteral Feeding Tubes: A Clinician's Guide, located at https://nutritioncare.org/wp-content/uploads/2026/04/Medications-Via-EN-Tubes.pdf, identified prior to administering medications through a g-tube, medications should be verified for right client, right medication, right dose, right time, right route, and right documentation. When administering medication through a g-tube, medications should be crushed and diluted with 15-20 milliliters (ml) of purified water (sterile or distilled) separately. Additionally, the head of the bed (HOB) should be elevated at least 30-45 degrees during medication administration and for at least 30-60 minutes after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · 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 monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R5) reviewed for pressure ulcers.Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5's current face sheet identified diagnoses of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), muscle weakness, type 2 diabetes, hypothyroidism (thyroid gland does not produce enough thyroid…
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 · D2026-04-14 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor daily oral intake and daily output; additionally, the facility failed to develop a system to monitor and assess daily intake and output for 1 of 1 resident (R5) reviewed who required nutritional and hydration support via a gastrostomy tube (g-tube).Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current face sheet identified diagnoses of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing) requiring the placement of a gastrostomy tube (g-tube) for nutrition and medication administration. R5's care plan dated 1/26/26 indicated R5 required tube feeding, hydration, and flushes per order, check tube placement prior to meds and feedings, elevating head of bed 30-45 degrees, care of tube per orders, and report signs of aspiration or…
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 21 citations
- Potential for harm · D2026-04-14 · 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
Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to standards of care to prevent respiratory infections for 1 of 1 residents (R16) who required oxygen for chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood).Findings include: R16's quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, identified R15 had intact cognition with no hallucinations, delusions, or rejection of care with admission date of 11/21/25. R16's admission record indicated on 2/18/26, R16's primary diagnosis was end stage renal disease with secondary diagnoses of chronic respiratory failure with hypoxia, biventricular heart failure (heart not working correctly), dependency on supplemental oxygen, unspecified right bundle-branch block (condition where electrical conduction in the heart is impaired), thoracis aortic ectasia (dilation or bulging in aorta in the chest), and atrial fibrillation (heart not beating correctly). Additional secondary diagnosis, dated 1/21/25, included:…
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 · D2026-04-14 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment), ensure contact information for dialysis clinic was on the care plan and ensure orders were accurate for monitoring dialysis site for 1 of 1 residents (R16) reviewed for dialysis care and services. Findings include: R16's quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, identified R16 had intact cognition with no hallucinations, delusions, or rejection of care. R16 required maximum amount of assistance or was dependent on staff for all Activities of Daily Living (ADLs) except showering (which R16 refused) and oral hygiene/eating which required staff set up. In addition, the MDS outline R16 received hemodialysis while a resident at the facility. R16's admission record indicated on 2/18/26, R16's primary diagnosis was end-stage renal disease. A secondary diagnosis, dated 11/21/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 1 primary care physician assistant (PA-A) had appropriately managed the care for 1 of 1 resident (R5) who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube). Refer to F684Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current, undated care plan indicated the following:-urinary incontinence: report changes in…
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 · D2026-04-14 · 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 record review, the facility failed to identify irregularities in monthly drug regimen monitoring review for 1 of 5 residents (R15) reviewed for unnecessary medications who received antipsychotic medications. Additionally, the facility failed to identify potential medication side effects for 1 of 1 resident (R5) reviewed for medication administration.Findings include: R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had no cognitive impairment and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS recorded R15 consumed antipsychotic, antidepressant, and antianxiety medications. Review of the 7/24/24, Olanzapine guidelines, located at: https://www.drugs.com/olanzapine.html#side-effects, identified olanzapine may cause serious side effects such as low blood pressure. Common side effects of olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or…
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 · D2026-04-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 a medication administration error rate of less than 5 percent (%) resulting in an 8.57 % medication error rate, identified during 3 of 25 medication administration observations. Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5's physician's orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids) -prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach. -folic acid (vitamin) 1 mg via g-tube daily -apixaban (blood thinner) 2.5 mg via g-tube twice daily -metoprolol tartate (blood pressure)…
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 · D2026-04-14 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct 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 implement their facility assessment to identify 1 of 1 resident (R5) who required specialty care and services and the facility failed to train and perform skill competencies as outlined in the facility assessment.Refer to F684 Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5 was admitted to the facility on [DATE] with an admission diagnosis of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), muscle weakness, type 2 diabetes, hypothyroidism (thyroid gland does not produce enough thyroid hormone, symptoms include fatigue, weight gain, cold intolerance, and depression), hyperparathyroidism (parathyroid gland produces too much hormone, symptoms include high blood calcium levels, feeling weak, nausea, vomiting, loss of appetite, constipation, and abdominal pain), 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 · D2026-04-14 · tag F0841 — isolatedDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 1 medical director had appropriate oversight of policies and procedures and ensured appropriate medical care was being provided for 1 of 1 (R5) resident who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube).Refer to 684 Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current, undated care plan indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-14 · 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 enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R5, R20) reviewed for transmission-based precautions.Findings include: R20's quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, identified R20 had intact cognition with no hallucination, delusions or other behavioral symptoms noted and was dependent on staff for activities of daily living (ADLs) except eating which R20 required maximal staff assistance. The MDS indicated R20 had an indwelling catheter. During an observation on 4/8/26 at approximately 7:20 a.m., RN-A was observed to enter R20's room and performed hand hygiene prior to entering room with hand sanitizer. A plastic bin was observed outside the doorway and inside the bin were personal protective gowns and gloves. Hand sanitizer was available from a dispenser on the wall. On the door, was a single page sign hung indicating Enhanced Barrier Precautions. Signage was orange in color, CDC…
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 · D2026-04-14 · tag F0941 — isolatedDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
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 staff completed mandatory communication training for 2 of 10 staff (nursing assistant (NA)-A, licensed practical nurse (LPN)-B) reviewed for training requirements. This had the potential to affect all 34 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated the facility had developed a training program that included an orientation process and ongoing training for all new and existing staff to ensure the programs meet the regulatory requirements. The assessment indicated all staff were to receive training in communicating effectively. During an interview on 4/13/26 at 10:59 a.m., administrator stated she was responsible for overseeing and ensuring all staff completed the required training. During a follow up interview on 4/14/26 at 11:06 a.m., the administrator was informed the education on effective communication was not found the personal files she had provided for LPN-B and NA-A. Administrator…
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 · D2026-04-14 · tag F0944 — isolatedConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement 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 interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement training for 6 of 10 staff (registered nurse (RN)-A, licensed practical nurse (LPN)-B, nursing assistant (NA)-A, NA-D, NA-E, and NA-F) reviewed for training requirements. This had the potential to affect all 34 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated the facility had developed a training program that included an orientation process and ongoing training for all new and existing staff to ensure the programs meet the regulatory requirements. The assessment indicated all staff were to receive training in quality assurance and performance improvement (QAPI). During an interview on 4/13/26 at 10:59 a.m., administrator stated she was responsible for overseeing and ensuring all staff completed the required training. During a follow up interview on 4/14/26 at 11:06 a.m., the administrator was informed the education 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 · Fcited before2025-02-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled and dated. This had the potential to affect 28 of 28 residents, staff and visitors who may eat from the facility kitchen. Findings include: During an initial tour of the kitchen on 2/3/25 at approximately 1:51 p.m., while verifying temperatures of the refrigerators, it was identified a box of oranges dated 12/31/24 with what looked like some white fuzz on one of the oranges and brown liquid coming from a bag of grapes. During a follow up observation and interview on 2/5/25 at 11:30 a.m., dietary aide (DA)-B identified a half gallon of expired milk with an expiration date of 1/27/25 on the front of the container and a can of soda and opened bottle of water next to the milk. DA-B was unaware what the half gallon of skim milk was used for and why the soda was in the refrigerator. DA-B indicated this was one of the main refrigerators used to store the prepared foods served to the residents. During 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 before2025-02-06 · 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 record review, the facility failed to ensure proper use of personal protective equipment (PPE) during cares for 1 of 3 residents (R14) reviewed for enhanced barrier precautions (EBP). Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 was cognitively intact and had surgical repair of deep ulcers. R14's provider orders included enhanced barrier precautions d/t surgical wound to left ankle. R14's diagnoses list included osteomyelitis (bone infection) to ankle and foot. R14's care plan indicated history of streptococcal arthritis (type of infection) to left ankle and foot, surgical incision and deep tissue injury to left foot, and EBP related to surgical wound to left ankle. During an observation and interview on 2/3/25 at 2:57 p.m., an orange sign indicating EBP was posted on the door outside R14's room. A shelving unit containing gowns and gloves was located across the hall outside another resident's room. A second cart containing PPE 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 · E2023-12-06 · tag F0881 — failed to use antibiotics responsibly — patternImplement 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 develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 5 of 5 residents (R3, R8, R10, R14, R21) who were prescribed antibiotics prophylactically. This deficient practice had the potential to affect all 5 residents. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated admission to facility on 1/5/23. R3's diagnoses dated 12/7/23, indicated R3 with diagnoses of cellulitis of left lower limb, hypertensive heart disease with heart failure, obsessive compulsive disorder, anxiety, congestive heart failure, peripheral vascular disease, and depression. R3's physician orders, with revision date of 11/9/23 indicate R3 receiving Cefadroxil Oral Capsule 500 mg[milligrams] (Cefadroxil) with directions to Give 1 capsule by mouth two times a day for antibiotic. R3's orders lacked an indication for use and end date was not filled in. R8 R8's quarterly MDS…
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 · E2023-12-06 · 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 implement the current standards of vaccinations regarding pneumonia for 5 of 5 (R2, R7, R8, R10, R19) over [AGE] years old whose vaccination histories were reviewed. Findings include: The Center for Disease Control and Prevention (CDC) identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R2's immunization record from the electronic medical record (EMR) indicate R2 received PCV20 at [AGE] years of age on 2/8/2005 and PCV13 at age [AGE] years of age on 7/17/2015. Per CDC guidance if individual receives the PCV13 at any age, then PCV20 to be administered after 5 years or…
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 · E2023-12-06 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake 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
Based on observation and interview, the facility failed to ensure a clean, sanitary, and homelike environment when R19's curtain was observed to be in disrepair. In addition, the facility failed to ensure a homelike environment for all 23 residents when carpet in the lobby at the entrance to the facility were observed to be darkly stained and soiled. Findings include: Curtain During an observation on 12/5/23 at 7:11 a.m., of R19's room, half of one curtain was hanging off the curtain/drapery apparatus with two feet of the curtain resting directly on the wall mounted baseboard heater that was directly under the window. During an interview on 12/5/23 at 9:02 a.m., maintenance director (MA) stated work orders from staff for maintenance issues in the facility were to go through an electronic messaging system. MA stated issues such as a broken call light, burned out light bulb, leaking faucet and, items in disrepair were to be included in this messaging system. MA stated he was not informed of R19's loose curtain by staff. MA stated, I would need to be notified of the curtain hanging…
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 · D2023-12-06 · 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 interview and document review, the facility failed to ensure routine bathing was offered or provided to promote good hygiene for 1 of 2 residents (R2) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares. Findings include: R2's significant change Minimum Data Set (MDS)assessment, dated 10/5/23, indicated R2 had intact cognition and diagnoses of diabetes, epilepsy, hemiplegia and hemiparesis (paralysis) following a cerebrovascular accident (damage to the brain) affecting his dominant right side, amputation of left upper limb above the elbow leaving him unable to use his only hand. R2's care plan goal with revision of 6/9/18, indicated R2 required assistance of one to eat, dress, personal hygiene, toileting, and to propel his wheelchair. R2's [NAME] (used by nursing assistants), indicated nursing assistant staff to shave him. During observation on 12/4/23 at 12:55 p.m., R2 with full set of whiskers below nose and covering cheeks, chin, and neck. During observation…
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 · D2023-12-06 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to complete annual performance reviews for 5 of 5 nursing assistants (NA-A, NA-B, NA-C, NA-D, NA-E) whose employee files were reviewed. This had the potential to affect all 24 residents who resided at the facility. Findings include: During interview with director of nursing (DON) on 12/6/23 at 10:22 a.m., DON stated facility staff education, in-services, and training are the responsibility of DON and human resources director (HRD) and should be completed annually. Performance reviews for five nursing assistants were reviewed with DON. The DON stated she had not completed the annual performance reviews for NA-A, NA-B, NA-C, NA-D, and NA-E in the prior year. DON stated, it's important to identify the areas that the staff do well, where they need to improve, areas of interest for future skills building, and it helps administration identify areas of care needing improvement for resident care. Making sure our staff is fully trained, assessed, and evaluated is key to providing the best care possible to the residents. A policy…
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 before2023-12-06 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and document review, the facility failed to label and date food items in the dietary refrigerator. Findings include: During the initial kitchen tour with dietary manager (DM) on 12/4/23 at 11:52 a.m., there was an undated, unidentified clear plastic bag in the refrigerator. During an interview on 12/4/23 at 12:01 p.m., Cook-A stated the contents was beef cubes which was placed in the refrigerator week ago and since identified will be discarded by the DM. During an interview on 12/4/23 at 12:15 p.m., DM stated expectation would be all foods in refrigerators and freezers to be clearly marked and dated. Review of facility Food Storage policy revised 8/16/22, indicated left-over foods will be clearly labeled and dated before being refrigerated, and used within 3 days and all left-over foods will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
- Potential for harm · Dcited before2023-12-06 · 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 provide appropriate hand hygiene when providing care, and handling of a catheter bag and tubing for 1 of 1 resident (R15) reviewed for infection prevention and control. Findings include: R15's quarterly Minimum Data Set (MDS)assessment dated [DATE], indicated a moderate cognitive impairment, and R15 had an indwelling urinary catheter. R15's medical diagnoses included type two diabetes, and flaccid neuropathic bladder (the urinary bladder does not expand and contract effectively). R15's active provider order started 11/27/23, directed to maintain a sterile, closed, gravity urinary catheter system; and always keep the collection bag below the bladder level. R15's care plan directed nursing staff to check catheter tubing for proper drainage and positioning, provide indwelling catheter care every shift and as needed, and keep drainage bag of catheter below the level of the bladder at all times (to prevent urine from seeping back into 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 · D2023-12-06 · tag F0924 — isolatedPut firmly secured handrails on each side of hallways.
What the surveyor found here — an excerpt from the official record, may be distressing
During observation and interview, the facility failed to ensure hand rails were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails. Findings include: During observation on 12/5/23 at 2:11 p.m., handrail in main lobby observed to be pulling away from the wall by half an inch. Eight handrails along the 100 wing of facility were also loose and not tightly secured. During interview with maintenance director (MA) on 12/5/23 at 2:19 p.m., MA indicated the affected handrails were a concern for safety and, should be secured tightly. MA stated he was unaware of the loose handrails in the facility. During interview with director of nursing (DON) on 12/5/23 at 2:29 p.m., DON moved the affected handrails in the facility and stated, this is not secure and, we need to get these fixed now. This is a safety concern. Facility policy titled Handrails Policy with date implemented of 06/16/2022, stated compliance guidelines of: 1. All handrails will be firmly secured. 2. Secured handrails means handrails that are firmly…
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 · C2026-04-14 · 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 the most recent survey results were posted in a prominent location and readily accessible to person wishing to review such information. This had potential to affect all 34 residents residing in the nursing home or any visitors who wanted to review this information. Findings include: The CMS Provider History Report, dated 4/3/26, identified the completed recertification for the previous three years, with the most recently completed recertification survey having exited on 2/6/25. On 4/8/26 at 1:34 p.m., an informal resident council meeting was held with R10, R15 and R30. The residents were asked, as part of the meeting, if the most recent survey results were readily posted within the facility for them to review at leisure. However, none of the residents voiced they knew the location or these results, nor had the results been discussed with them during the resident council meetings. During an interview and tour on 4/10/26 at 8:22 a.m., administrator stated she was responsible for the survey results…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to NORTH SHORE HEALTHCARE — 59 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 | 1 of 5 | 2.7 | -1.7 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; 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 |
|---|---|---|---|---|
| NSHC WISCONSIN LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 12/28/2016 |
| BAUMANN, TROY | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2017 |
| HOEHN, JEFFREY | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2017 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2024 |
| CLIFTONLARSONALLEN LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2025 |
| CONTINUUM THERAPY PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2017 |
| NSH REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| WIPFLI LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2025 |
| BELONGIA, CHRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2019 |
| FRANTA, PETER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2023 |
| GEE, DARREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/30/2021 |
| GREER, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/29/2023 |
| LADNER, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/09/2023 |
| PATZER, COLLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/14/2023 |
| PURTELL, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2018 |
| GPH LA CRESENT LLC | Organization | ADP OF THE SNF | — | since 02/01/2017 |
CMS files one row per role, so the 37 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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 $172K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 245319. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-14, 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.