Colonial Manor Nursing Home
403 Colonial Avenue, Lakefield, MN 56150 · For profit - Corporation · 37 certified beds · (507) 662-6646 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
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 | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 10.9% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.5% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 13.6% | 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 | 0.0% | 4.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 4.5% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.5% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.4% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 39.9% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.3% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.3% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.40 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 1% 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 | 45.3%CMS range 34.1–58.9 | 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 6.3–15.0 | 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 | 1.26 | 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 37 beds and averages 23.9 residents a day — about 65% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 6.37 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.46 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 5.31 hrs/resident/day on weekends vs 6.79 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.56 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above 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 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 10 most serious are shown; the remaining 22 are one tap away and print in full.
- Potential for harm · F2026-01-29 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to have a registered nurse (RN) on duty 8 consecutive hours a day, 7 days a week for 3 of 18 days reviewed.Findings include: Review of the 18 sampled days between 7/1/25 through 1/1/26 identified:On 11/15/25 the RN had only worked 4.5 hours that day.On 7/4/25 there was no RN coverage for that day.On 8/2/25, the RN had only worked 6.25 hours that day. Interview on 1/28/26 at 3:51 p.m., with the health unit coordinator who identified he was responsible for the schedule and to ensure there was an RN working 8 consecutive hours a day. If there was a call-off it was the responsibility of the case manager to work that shift for the RN coverage. He confirmed no RN had worked on 7/4/25. Interview on 1/29/26 at 2:50 p.m., with director of nursing identified that the health unit coordinator was responsible for the schedule and was very good at letting her know if there was not an RN scheduled to work. When that occurred, she revealed that the case manager or herself would provide that RN coverage. The expectation was that the 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 · Fcited before2026-01-29 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 designate a qualified person to serve as the director of food service to oversee the dietary department in the absence of a full time dietitian. This had the potential to affect all 26 residents, visitors and staff who consumed food from the kitchen.Findings include: Interview on 1/27/26 at 9:30 a.m. with the dietary manager (DM), identified she was not yet certified and was waiting for direction as to what courses she needed to complete to obtain her certification. She reported she did have her SERV Safe certification and had previously worked as the main cook, prior to taking the position as DM. She reported the facility had a contracted registered dietitian that came to the facility once a week on Tuesdays and was available via phone or email between visits. She identified when the RD came to the facility, she completed the assessments, reviewed dietary items with her, and assigned leaning topics she was to complete online. She reported she had not had anyone work alongside her to provide training in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-29 · 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 and interview, the facility failed to maintain a clean and sanitary kitchen with appropriately clean food preparation equipment identified as a buildup of dust and grease on exhaust vents and food residue on food preparation equipment. This had the potential to affect all 26 residents who received food prepared in the facility kitchen.Findings include: Based on observation and interview on 1/27/26 at 9:30 a.m. with the dietary manager (DM) the following areas of concern were identified:1) 2 of 2 rectangular exhaust vents located above the doors on the dining room side of the kitchen were covered with a black, thick, furry appearing substance. The vents were pointed toward the stove and food preparation areas.2) Vents on the refrigerator and freezer on the dining room side of the kitchen, were covered with a thick layer of dust, and the dust was noted to be moved by the circulating air.3) A chest type (milk) cooler positioned between the refrigerator and freezer on the dining room side of the kitchen, had a red liquid dried on the inside seal, in addition to a…
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 before2026-01-29 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility failed to submit accurate staffing information for payroll-based journal (PBJ) for 1 of 4 quarters (quarter 4) reviewed.Findings include: Review of 2025, quarter 4 PBJ staffing Data Report 1705D identified the facility failed to have licensed nursing coverage 24 hours a day. The report identified the following dates 7/4/25 Friday, 7/5/25 Saturday, 7/6/25 Sunday, 7/19/25 Saturday, 7/20/25 Sunday, 8/2/25 Saturday, 8/3/25 Sunday, 8/9/25 Saturday, 8/10/25 Sunday, 8/17/25 Sunday, 8/30/25 Saturday, 9/13/25 Saturday, and 9/27/25 Saturday. Review of the above dates and facility staff timecard punches for the dates identified, showed that the facility did have licensed staff on duty each shift on each day identified. Interview on 1/27/26 at 3:15 p.m., with the regional director of skill operations identified there had been PBJ issues at each of the facilities she consulted. She reported the facility had not been without 24 hours licensed nursing staff and she was unsure why that had triggered for the facility. The business office manager was responsible for submitting the PBJ…
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 · F2026-01-29 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee for improvements had a developed measurable goal, action plan identified to reach the goal and analysis of the data collected on the improvement activities. This had the potential to affect all 26 residents residing in the facility.Findings include: Review of the quarterly QAPI meeting minutes provided identified:1) QAPI meeting minutes from 2/18/25, identified agenda for February, March, and April, included dietary review, diagnosis of malnutrition, at-risk of malnutrition, supplements, fluid restrictions, modified diets, low body mass index (BMI), high BMI's, and weight loss. Included with the documentation was a weight variance report from 1/18/25 through 2/18/25, which listed the residents' name and their weights, their BMI, and any change in weight. There was no identified goal, no action plans, or analysis of the data that was brought forth.2) QAPI meeting minutes from 5/15/25, identified agenda for February, March, 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 · F2026-01-29 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure the infection preventionist (IP) brought a thorough report to the Quality Assurance Performance Improvement (QAPI) meetings on the infection control program. Findings include: Review of the 2/18/25, 5/15/25, 8/19/25, and 12/16/25 quarterly QAPI information provided, was a sign in sheet and an agenda for the meeting. There were no minutes provided. Interview on 1/28/26 at 8:24 a.m., with the interim director of nursing (IDON) who was the facility designated infection preventionist identified when staff called off for their shift the manager for their department filled out a form that was sent to the health unit coordinator (HUC) and he was responsible for tracking staff illness. The IDON revealed that she did not track, analyze or include staff illness in her QAPI reports and that staff illness was not discussed at QAPI. She was responsible for overseeing the infection control program. She reported she was certified in another state; however, she was unable to provide any information on completion of a program 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 · Fcited before2026-01-29 · 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
Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness dependent upon their symptoms for 3 of 3 months reviewed. This has the potential to affect all 26 residents who resided at the facility.Review of the facility staff illness surveillance identified the following1.On 10/13/25 licensed practical nurse (LPN)-A called in for his shift with symptoms of glassy eyes, sore throat, and feeling sick. The surveillance did not identify the last day worked, the date symptoms resolved, or when LPN-A returned to work.2.On 10/20/25 nursing assistant (NA)-A called in with symptoms of a sore throat and a temperature of 100.1. Her last day worked was 10/19/25. The staff illness log did not identify when NA-A was eligible to return to work or her actual return to work date. Under a column labeled notes it said she had been gone a few days, and she brought in a physician note.3.On 11/25/26 the facilities health unit coordinator (HUC) called in with symptoms of nausea, vomiting,…
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 before2026-01-29 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's interim director of nursing (IDON)) had completed specialized training in infection prevention and control. This had the potential to affect all 26 residents residing in the facility. Findings include: Review of the facility assessment identified the designated facilities infection preventionist was the IDON. Infection prevention and control program (System to prevent, identify, report, investigate, and control infections) has a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease (IPCP), for all residents, staff, volunteers, visitors and other individuals receiving services under contractual arrangements based upon the facility assessment, and following accepted national standards. Our facility uses multiple tools to control and prevent infection, including 'support from outside organizations, interactions and training with the MN department of health ICAR team, having a designated infection…
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 before2026-01-29 · 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 development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 3 of 3 residents (R3, R4, and R16). This deficient practice had the potential to affect all 26 residents who resided in the facility. Findings include: R4's 10/15/25, physician order identified the facility was to administer cefdinir 300 milligrams (MG) by mouth twice daily for 7 days for a diagnosis of a urinary tract infection (UTI). R4's October 2025, administration record identified he received cefdinir 300mg by mouth twice daily for 7 days starting on 10/15/25. R3's 10/29/25, physician order identified the facility was to administer Augmentin 875mg, twice daily for 7 days for a diagnosis of aspiration pneumonia. R3's October 2025, administration record identified he received Augmentin 875mg, twice daily for 14 days starting on 10/29/25. R16's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to provide timely beneficiary notice to 1 of 3 (R31) sampled residents.Findings include: R31's last day of Medicare part A skilled services ended on 11/18/25. R31 was provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) on 11/18/25 at which time R31 had signed the notice. R31 was provided with the CMS-10123 Notice of Medicare Non-Coverage on 11/18/25 at which time R31 had signed the notice. R31 was not provided with adequate time to appeal the decision and make a request for an independent reviewer authorized by Medicare to review the decision to end the services if R31 had wanted to. Interview on 1/28/26 at 3:13 p.m., with the regional administrator identified that residents were to be given 2-day notice before Medicare part A skilled services were to end. Her expectation was that the facility would provide timely notices to residents who were ending Medicare part A skilled services to ensure the resident had time to appeal the decision if they wanted to. A policy 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.
Show the remaining 22 citations
- Potential for harm · D2026-01-29 · 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
Based on interview and document review the facility failed to have a discharge summary for 1 of 1 (R31) sampled residents. Findings include: R31's 12/12/25, accepted discharge Minimum Data Set (MDS) assessment identified R31's cognition was moderately impaired. R31 was independent with care, and participated in speech, occupational and physical therapy. R31 had been discharged to home/community. R31's 11/20/25, progress notes identified that R31 was excited to return to the assisted living facility. Staff reviewed the discharge summary with R31 and faxed R31's discharge orders to the pharmacy. R31's 11/21/25, progress note identified R31 discharged via private vehicle accompanied by caregiver. There was no recapitulation of R31's stay documented in the progress notes. R31's 11/21/25, Transition of Care/Discharge Summary form identified a section on the form to document a recapitulation of R31's stay which was left blank. Interview on 1/29/26 at 1:08 p.m., with director of nursing (DON) identified there was a place on the facilities Transition of Care/Discharge Summary form to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-29 · 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
Based on observation, interview and document review the facility failed to prevent potential accident hazards for 1 of 1 resident (R5) due to wandering behaviors into an unsecured area with steep cement stairs down to a cement floor.Findings include: R5's accepted 1/2/26, Significant change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and wandered throughout the facility including into other resident spaces. R5 had diagnoses which included: Alzheimer's disease, dementia with agitation, history of falls, and anxiety. Observation on 1/27/26 at 3:16 p.m. noted R5 wandering in her wheelchair as she went up and down each of the halls and attempted to open closed doors in the short hall across from the director of nursing (DON) office. She then turned to the right and went down the hall toward the main door and dining room area,. An unknown staff member intercepted R5 and took her to an activity that was in progress. Observation on 1/27/26 at 6:30 p.m. noted R5 transporting herself in her wheelchair down the [NAME] Hall where she attempted to enter a…
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 · D2026-01-29 · tag F0732 — isolatedPost 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 include the facility census in their daily posting of nursing staff for 29 of 29 days reviewed.Findings include: Observation on 1/27/26 at 6:52 a.m., in the front entry of the building prior to entering the main door of the facility was a daily staff posting hanging up on the bulletin board titled Colonial Manor Nursing Home. The form included the facility name, a place to document the date, the census, and a list of positions for each shift. The form was dated 1/27/26 and the positions for each shift were circled with a total number of hours for that position for that shift. The census section of the form was blank. Interview on 1/27/26 at 6:55 a.m., with registered nurse (RN)-A who was working as the charge nurse upon entry to the facility was unaware of the current facility census and she asked the trained medication aid (TMA)-A working on the medication cart if she knew the census. The TMA-A reported she was not sure and then proceeded to look up in the facility electronic record and reported that 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 before2026-01-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 2 of 5 sampled residents (R6, and R14) were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).Findings include: Review of the current Centers for Disease Control (CDC): Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV 21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV 21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV 21) at any age and a PPSV23 at or after the age of [AGE] years old. R6's 8/18/25 comprehensive Minimum Data Set (MDS) assessment identified he was [AGE] years old. He had diagnosis of renal failure, thyroid disorder, and dementia. Section O-Special Treatments and Programs identified R6's pneumococcal vaccinations were not up to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-21 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 25 residents who resided in the facility. Findings include: During an interview on 11/18/24 at 12:25 p.m., dietary manager (DM)-J stated she had been employed at the facility since 12/18/23 and was not a certified dietary manager nor had she started any classes. DM-J stated she was notified today the administrator was going to get her signed up for the certification class. DM-J stated she does have a Food Safety Certificate, which she completed in 2019. During an interview on 11/20/24 at 10:45 a.m., the administrator was aware DM-D was not certified as a dietary manager. The administrator stated she understood the registered dietician coming once a week would be adequate until DM-J got her certification. The administrator stated, DM-J has not been signed up for her dietary certification classes. Dietary manager job description undated,…
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 before2024-11-21 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report for quarter 3 of 2024, which included dates from 4/1/24, to 6/30/24, triggered for: Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage. The following infraction dates were identified: 5/25/24, 6/8/24, 6/9/24, 6/16/24, 6/1/24, 6/22/24, 6/23/24, 6/24/24, 6/29/24, and 6/30/24. Review of nursing staff schedules for each infraction date indicated a licensed nurse had been scheduled each of the three shifts (days, evenings, and nights). The daily staffing postings for each infraction date indicated a licensed nurse was scheduled on each shift. During an interview on 11/20/24 at 11:10 a.m., nursing department coordinator (NDC)-A who was responsible for…
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 before2024-11-21 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 25 residents residing in the facility. Findings include: On interview on 11/19/24 at 10:29 a.m., the director of nursing (DON), indicated she started her employment at the facility in July 2024 and started doing the infection control role in October. The DON indicated she is enrolled in the Centers for Disease Control (CDC) infection preventionist course but has only completed one module so far and isn't very far into the training course. The DON added the role was going to be split between her and RN-A, also identified as Minimum Data Set (MDS) coordinator. On interview 11/19/24 at 10:23 a.m., RN-A indicated she is new to the infection preventionist role and has had no training at this time. RN-A stated she started at the facility at the end of June 2024 and was told to focus on MDS training first. RN-A indicated she is enrolled in a Boot Camp for Infection Control…
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 before2024-11-21 · 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 implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance for 4 of 5 residents (R9, R19, R20, R25) reviewed for antibiotics. This had the potential to affect any of the 25 residents who resided in the facility who might use antibiotics. Findings include: Review of the monthly infection control log dated 7/2024, 8/2024, 9/2024, 10/2024 and 11/2024, identified residents who had been identified as having an infection and had been administered an antibiotic and had included the floor plan of the facility. Review of 7/2024, surveillance log identified R20 had a urinary tract infection (UTI). R20 was admitted [DATE]. R20's face sheet had diagnoses of dementia with anxiety and traumatic brain injury. She was prescribed an antibiotic Macrobid that was started on 7/28/24. The surveillance log lacked indication of the antibiotic dosages and when or if the infection had resolved.…
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 · D2024-11-21 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow their grievance process for missing personal property for 1 of 1 resident (R19) who reported missing property. Findings include: R19's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R19 had moderately impaired cognition. On interview 11/18/24 at 1:54 p.m., R19 stated he has had multiple packs of handkerchiefs lost when sent to laundry along with a couple shirts since his admission to the facility January 2024. R19 stated he is not sure how many handkerchiefs come in a pack but he has told multiple staff about his missing items. On interview 11/20/24 at 9:41 a.m., nursing assistant (NA)-A stated when residents inform them of missing belongings including clothing, would tell the charge nurse. NA-A was unsure what happens after that. On interview 11/20/24, at 9:45 a.m., NA-B stated staff fill out a missing belonging sheet and inform the charge nurse of the missing belongings. NA-B added they also put…
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 · D2024-11-21 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure allegations of abuse were reported to the administrator and the State Agency (SA) timely for 1 of 1 resident (R24) reviewed for allegations of abuse. Findings include: Review of the 11/13/24 at 10:50 a.m., report to the SA identified on 11/12/24, at 6:15 a.m., resident informed staff the nursing assistant stated You better start cooperating with me or I will tell your husband and he will yell at you and You better be nice or your husband will yell at you. On interview 11/18/24 at 1:47 p.m., R24 denied any recent alleged events with verbal abuse. On interview 11/18/24 at 4:46 p.m., family member (FM)-A stated the facility did notify her regarding an event that occurred last week sometime (unable to identify the date) with potential verbal abuse. FM-A indicated R24's memory is very poor and would not recall any events from the past week. On interview 11/19/24 at 9:58 a.m., the director of nursing (DON) indicated she was notified of the alleged abuse event on 11/13/24 regarding R24, and reported it that same morning.…
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 · D2024-11-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a residents hospice status was accurately coded on the Minimum Data Set (MDS) assessment for 1 of 1 residents (R15) reviewed for hospice and end of life. Findings include: R15's facesheet printed on 11/20/24, included diagnoses of protein-calorie malnutrition and encounter for palliative care. R15's current, quarterly MDS assessment dated [DATE], indicated R15 had moderately impaired cognition, had clear speech, could understand, and be understood. Hospice was not marked on the MDS. R15's significant change MDS assessment dated [DATE], indicated R15 was receiving hospice care. A progress note dated 7/3/24, indicated the provider faxed an order requesting hospice admission. During a telephone interview on 11/20/24 at 9:29 a.m., hospice agency administrative assistant (AD)-F stated R15 was enrolled in hospice on 7/8/24. R15's certification of terminal illness (CTI) diagnosis was protein calorie malnutrition. During an interview on 11/20/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a care plan was revised to include hospice care for 1 of 1 residents (R15) reviewed for hospice and end of life. Findings include: R15's facesheet printed on 11/20/24, included diagnoses of protein-calorie malnutrition and encounter for palliative care. R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R15 had moderately impaired cognition, had clear speech, could understand, and be understood. R15's progress notes dated 7/3/24, indicated the provider faxed an order requesting hospice admission. R15's care plan initiated on 5/1/23, had no reference to R15 receiving hospice or palliative care. During a telephone interview on 11/20/24 at 9:29 a.m., hospice agency administrative assistant (AD)-F stated R15 was enrolled in hospice services on 7/8/24. During an interview on 11/20/24 at 9:54 a.m., registered nurse (RN)-A who was also the MDS nurse, stated if a resident was receiving hospice services, it would be identified 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 · D2024-11-21 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, facility failed to document a complete recapitulation of stay for 1 of 1 resident (R28) reviewed for discharge. Findings include: R28's facesheet printed 11/20/24, identified an admission date to facility of 7/8/24 with diagnoses including: pressure ulcer of left foot (bedsore injury to the skin and tissue below the skin), depression, osteomyelitis (infection in bone) and paraplegia (paralysis that mostly affects the movement of the lower body). R28's discharge orders were dated 10/24/24, and signed by the provider. A progress note dated 10/25/24 at 9:51 a.m., by registered nurse (RN)-B included resident discharged to home with wife. Personal belongings, over the counter medication were taken home. Discharge orders reviewed with wife and resident and they state understanding. The medical record lacked a discharge summary. On interview 11/20/24 at 4:43 p.m., registered nurse (RN)-H, also identified as regional director of skilled care, confirmed she was not able to locate a discharge summary in the medical record and added there has been a turn…
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 · D2024-11-21 · 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 observation, interview and document review, the facility failed to document and monitor weight loss for 1 of 1 resident (R24) who had weight loss. In addition, the facility failed to obtain accurate weights for 2 of 2 residents (R24, R4) who were evaluated for nutrition. Findings include: R24's facesheet printed on 11/20/24, included diagnoses of stroke affecting left side, Parkinsonism (movement related disorder), dementia, mild with anxiety, hypoglycemia (low blood sugar), hyponatremia (low sodium level), and dysphagia (difficulty swallowing). R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had severe cognitive impairment, required setup help for eating and was dependent for transfers, mobility in wheelchair, dressing, and personal cares of activities of daily living (ADL's). No weight loss or gain. R24's care plan dated 10/23/24, indicated R24 was at risk for nutritional compromise related to right sided stroke and Parkinson's disease. Goals included resident will have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R26) who had a urinary ostomy Findings include: R26's facesheet printed on 11/20/24, included diagnoses of neuromuscular dysfunction of the bladder (when the nerves and muscles that control the bladder don't work properly), bladder-neck obstruction, and a urinary diversion device - a urinary ostomy (an opening in the abdominal wall to redirect the urine). R26's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R26 had moderately impaired cognition, clear speech, could understand and be understood. R26, who didn't walk, required staff assistance for most activities of daily living (ADL's), including toileting. R26's physician order dated 11/5/24, indicated to change two-piece urostomy pouch on Tuesday and Friday if leaking. During an observation on 11/19/24 at 1:20 p.m., observed an EBP sign hanging on R26's door which indicated staff were to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 have records of the pneumococcal vaccinations for 1 of 1 resident (R19) and the influenza vaccine for 2 of 3 residents (R19, and R7) reviewed for immunization protocol for who had a signed agreement to receive the influenza vaccine. In addition, the facility failed to document for 1 of 1 resident (R19), the influenza vaccine had been offered and education on risks/benefits was completed. Findings include: R19's medical record identified R19 had been admitted to the facility on [DATE]. R19's medical record lacked documentation of receiving any pneumococcal or influenza vaccines. R19's medical record lacked documentation of education on risks/benefits or declination of vaccines. Upon request of R19's record of vaccinations or refusal along with education completed, registered nurse (RN)-A confirmed 11/19/24 at 10:23 a.m., R19's record lacked documentation of any vaccinations and stated she would look further into it. Upon second request for vaccinations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-28 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 sufficient staffing was available to provide timely assistance with personal cares needs for 7 of 7 residents (R1, R2, R3, R4, R5, R6, and R7) who voiced concerns of inadequate number of staff to routinely meet their needs in a timely manner Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 10/18/24 alleged the vulnerable adult (VA) would push the call light to request staff assistance to use the bathroom and staff would take an hour to respond. Because of the extended wait time, the VA would not get to the bathroom in time and be incontinent of bowel and urine. R1 R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition. The MDS identified R1 required staff assistance with toileting, bathing, dressing, bed mobility, and transfers. Diagnoses included diabetes, Alzheimer's disease, history of urinary tract infections (UTI), and congestive heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to revise the care plan for 1 of 1 resident (R1) who had a change with activities of daily living (ADL's). Findings include: R1's admission minimum data set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses of Alzheimer's disease and anxiety. R1 required partial to substantial assist with adl's. No signs or symptoms of a possible swallowing disorder. R1's current weight was 178 pounds. R1's significant change MDS, dated [DATE], identified R1 required partial to substantial assist with adl's. Further identified R1 had coughing or choking during meals or when swallowing medications. R1's weight was 160 pounds. R1's Speech Language Pathologist (SLP) communication form to dietary and nursing, dated 6/19/24, identified R1 will need staff assistance with feeding at every meal, will also need frequent cues to sit up, as well as being fed. R1's progress note dated 6/19/24, identified R1 needed staff assistance with…
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 · D2024-07-24 · 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 comprehensively assess, monitor, develop and implement person centered interventions to prevent a pressure ulcer for 1 of 3 residents (R1) reviewed who entered the facility without a pressure ulcer. Findings include: R1's Braden Scale Comprehensive Risk assessment dated [DATE], identified R1 to score a 20 indicating no risk of pressure ulcers. R1 did not use a wheelchair and ambulated without an assistive device. Licensed nurse to assess skin weekly and as needed, will initiate plan of care to put a pressure reducing device for R1's bed. R1's admission minimum data set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses of Alzheimer's disease and anxiety. R1 required partial to moderate assistance with toileting and toilet transfers, required substantial assistance with chair/bed transfers and hygiene, and was frequently incontinent bladder and always continent of bowel. R1 was identified at risk for…
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 · D2024-07-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to develop an individualized toileting program to maintain or improve bowel/bladder continence resulting in a decline in continence for 1 of 1 residents (R1) reviewed for incontinence. Findings include: R1's admission minimum data set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses of Alzheimer's disease and anxiety. R1 required partial to moderate assistance with toileting and toilet transfers, required substantial assistance with chair/bed transfers and hygiene, and was frequently incontinent bladder and always continent of bowel. R1's Bowel and Bladder assessment initiated on 4/15/24 and was completed on 4/16/24 identified R1 had a trial of a toileting program since urinary incontinence was noted in this facility. R1's toileting program response was unable to determine or trial in progress, R1 was frequently incontinent of bladder and always continent of bowel. R1 required limited assistance with…
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 F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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 and sanitary environment in the kitchen when general cleaning had not been done and when personal items belonging to staff where observed in food prep areas. In addition, 2 of 2 fans in the kitchen were observed with dust and debris, blowing on clean dishes, a food prep (preparation) surface, a convection oven, and an industrial oven/stove. This had potential to affect all 27 residents who consumed food prepared in the kitchen. Findings include: During an observation and interview on 10/16/23 at 1:50 p.m., in the kitchen with cook (C)-A, observed two cell phones belonging to staff on or adjacent to, food prep areas. One phone was located on a counter between a hand washing sink and where C-A had been filling small plastic containers with food. In addition, another phone and personal beverages of staff including a tall, black thermal mug were observed on a shelf above a stainless steel food prep counter, along a plastic bottle of cold coffee and several cans of energy drinks. C-A stated these items belonged to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · 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 document review the facility failed to provide supervision for a 1 of 3 residents (R9) who was diagnosed with Alzheimer's disease and has a history of roaming and elopement. Findings include: R9's face sheet printed 10/19/23, included diagnoses of Alzheimer's disease (type of dementia that damages the brain, affects memory, thinking and behavior), psychosis (severe mental condition in which thought and emotions are so affected contact is lost with reality), and dementia (range of conditions that affects the brain's ability to think, remember and function normally). R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R9 had severely impaired cognition, unclear speech, sometimes understood, and sometimes understand others. The MDS identified R9 did not walk and used wheelchair for mobility. Further the MDS identified R9 required extensive assistance of one staff with eating and for locomotion. Behaviors included wandering occurred daily. Wandering impact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GR PARTNER COMPANIES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2018 |
| GRUBER, KARI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | 25% | since 01/01/2009 |
| GRUBER, NATHAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 25% | since 01/01/2009 |
| ROCHELEAU, DEAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 25% | since 01/01/2009 |
| ROCHELEAU, PAULA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | 25% | since 01/01/2009 |
| ALVARADO, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| GIESE, SHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/14/2024 |
| KAMSTRA, LEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2025 |
| RITTER, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2018 |
| PARTNERS SENIOR LIVING OPTIONS LLC | Organization | ADP OF THE SNF | — | since 12/01/2017 |
| ROCHELEAU, KIMBERLY | Individual | ADP OF THE SNF | — | since 06/01/2020 |
CMS files one row per role, so the 26 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $208K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 245572. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.