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Cura Of Le Sueur

621 South 4th Street, Le Sueur, MN 56058 · Non profit - Corporation · 50 certified beds · (507) 665-3375 Medicare & Medicaid certified

Call the home — (507) 665-3375 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Oct 2024Resident-funds citation (F0565)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,021 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,021 in federal fines (most recent 2024-10-03)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
621 S 4th St · (952) 442-8011 · Call to confirm hours
Pharmacy
101 S Main St · (507) 665-3301 · Call to confirm hours
Grocery
111 N Main St · (507) 200-4845 · Call to confirm hours
Park
S Ridgely St · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.5%18.2%15.4%typical
Long-stay residents who lose too much weight13.8%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder10.6%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.6%2.0%better
Long-stay residents with depressive symptoms5.1%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.2%4.0%3.3%worse
Long-stay residents on antianxiety or hypnotic medication10.6%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine92.3%96.1%95.3%typical
Long-stay residents with pressure ulcers10.7%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control24.9%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine94.6%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.

41.0% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.0%U.S. median 51.5%
Got home and stayed home
48.4%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 48.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.0%CMS range 24.7–54.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified85.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

2.19
RN hours/ resident / day
0.42
LPN hours/ resident / day
3.57
Aide hours/ resident / day
6.18
Total nurse hours/ resident / day
1.53
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 22.6 residents a day — about 45% occupied, or roughly 27 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 6.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.19 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.57 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 5.50 hrs/resident/day on weekends vs 6.45 on weekdays — 15% thinner on weekends. RN hours go from 2.46 to 1.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

4
deficiencies at the latest standard inspection (2026-02-24)
15
at the previous standard inspection (2025-01-16)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2024-10-03 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 12 of 25 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12) reviewed for drug diversion were free from misappropriation of their property when their medications were taken by a staff member. This resulted in diversion of 121 oxycodone tablets, one tramadol tablet and two doses of liquid lorazepam. The immediate jeopardy (IJ) began on 9/27/24, when registered nurse (RN)-A notified the director of nursing (DON) with her concerns that trained medication aide (TMA-A) had been signing controlled medications out of the narcotic logbook. However, TMA-A was not documenting medication in the medication administration record (MAR) as given. R1 and R2 notified RN-A and their provider they had not received as needed (PRN) medications. The facility initiated an internal investigation, which included additional narcotic record review and audits against electronic medical records. Discrepancies were found in the following records: R1, R2, R3,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2026-06-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure medications were administered according to physician orders which resulted in a significant medication error for 1 of 3 residents (R1) reviewed for medication administration. This resulted in actual harm for R1 when an increased dose of a diuretic (water pill) had been ordered but was later discontinued without a physician order. R1 did not receive an increased dose, nor any doses of prescribed diuretic for two days and subsequently developed shortness of breath, had to be sent to the emergency department (ED) where he received intravenous diuretic and needed to be hospitalized . The facility implemented immediate corrective action and corrected the deficient practice by 6/18/26, so the citation was issued at past non-compliance. Findings include: R1's face sheet dated 6/24/26, identified diagnoses of chronic systolic congestive heart failure (heart failure that occurs at the bottom of the heart), chronic kidney disease (a long-term condition…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-06-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a resident was comprehensively assessed and appropriately monitored for fluid volume status after a reported significant increase in daily weight for 1 of 3 residents (R2) reviewed for change in condition.Findings include: R2's face sheet dated 6/24/26, identified diagnoses of edema (swelling cause by excessive fluid trapped in the body's tissues), diabetes mellitus (condition that you body uses sugar as fuel), paraplegia (a condition where half of the body does not function), sick sinus syndrome (a group of heart rhythm disorders caused by a malfunctioning sinoatrial node (the hearts natural pacemaker). R2's Annual Minimum Data Set (MDS) dated [DATE], identified R2's cognition was intact, had no behaviors, no rejection of care, was dependent for bed mobility/transfers, and was administered a diuretic medication. R2's care plan dated 6/23/25, identified R2 had the potential for pacemaker malfunction/failure or altered cardiac…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · F2026-02-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain 1 of 1 ice machine to prevent potential contamination and to ensure food and drinks were served in a safe and sanitary manner. This had the potential to affect all 21 residents who resided in the facility.Findings Include:On 2/23/26 at 10:45 a.m., during the initial tour of the kitchen with the dietary director (DD-D), a Manitowoc brand ice machine located in a hallway adjacent to the kitchen was observed with white/grey chalky, powdery, hard, crusty, rock-like, lumpy deposits present on: the inside lid of the ice machine, the outside lid, the front exterior surface, and both side exterior surfaces. The buildup appeared consistent with lime scale and mineral deposits. The DD-D stated the ice machine had lime scale buildup and that maintenance staff were responsible for cleaning the ice machine. DD-D further stated that, as of approximately two weeks prior, the facility no longer had maintenance staff, and she was unsure who was responsible for ensuring the ice machine was cleaned. DD-D confirmed the ice machine 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-24 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups 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 establish and maintain a system to ensure concerns voiced during resident council meetings were addressed and follow up with residents. This had potential to effect 6 of 6 residents (R1, R4, R5, R9, R18, R20) identified to have attended the meetings.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment.R4's quarterly MDS dated [DATE], indicated no cognitive impairment.R5's admission MDS dated [DATE], indicated no cognitive impairment.R9's quarterly MDS dated [DATE], indicated no cognitive impairment.R18's quarterly MDS dated [DATE], indicated no cognitive impairment.R20's quarterly MDS dated [DATE], indicated no cognitive impairment.On 2/23/26 at 2:08 p.m., the activities director (AD)-F stated the resident council did not have a current president and further gave permission for the survey team to review previous minutes of resident council meetings. These minutes were provided and identified the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-24 · tag F0851 — isolated
    Electronically 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 4, 2025), 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 four of 2025, which included dates from 7/1/25-7/30/25, triggered for four or more days within the quarter with <24 hours/day licensed nursing coverage. The following infraction dates were identified: 8/3/25, 8/23/25, 8/24/25, and 9/6/25.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).On 2/24/26 at 10:25 a.m., the assistant director of nursing (ADON) stated they were responsible for scheduling nursing staff, stated there was always a licensed nurse working every day, on each shift - days, evenings, and nights. On 2/24/26 at 2:05 p.m., registered nurse…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a comprehensive skin assessment and monitoring of impaired skin integrity for 1 of 3 residents (R1) reviewed for skin care. Findings include: R1's hospital Discharge summary dated [DATE], identified invasive ductal carcinoma (cancer that starts in the cells lining the milk duct in the breast and breaks through the duct wall invading nearby breast tissue) had been discovered during a previous hospital stay 2/2025 and treatment had not begun yet. Current hospital stay was complicated by right breast pain with oncology follow-up 5/1/25 scheduled. Skin check identified tender, indurated (thickened/hard) right breast including the areola (pigmented area surrounding the nipple), without warmth and consistent with known breast cancer, likely lymphatic obstruction (blockage of lymph vessels which can lead to swelling). R1's face sheet dated 5/1/25, identified diagnoses of malignant neoplasm of lower outer quadrant of right breast (cancer). R1's care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-16 · tag F0725 — failed to have enough nursing staff — widespread
    Provide 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 provide sufficient staffing to ensure residents received care and assistance as needed. These deficient practices had the potential to affect all residents who resided in the facility. Findings include: Refer to F676: Based on observation, interview and document review the facility failed to ensure residents received assistance with meals for 3 of 3 residents (R1, R2, and R10) reviewed for dining who required staff assistance and/or supervision with meals. Refer to F684: Based on interview and document review, the facility failed to monitor weights per physician order for 1 of 1 resident (R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (R20 and R23). Refer to F688: Based on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R20, R22) reviewed for restorative services. Refer to F686: Based on 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-16 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing preventive measures to prevent the spread of influenza A, failed to post appropriate signage for 11 of 11 residents (R2, R9, R10, R79, R12, R4, R16, R1, R18, R22, R3) who exhibited symptoms of influenza A or had tested positive for influenza A, and further failed to ensure correct personal protective equipment (PPE) use. In addition; the facility failed to ensure correct use of gloves during wound care for 1 of 1 resident, (R16). This had the potential to affect all residents who resided at the facility. Findings include: R2's facesheet printed 1/15/25, indicated diagnoses of heart failure, pain syndrome, and kidney disease. R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors, and dependent on staff for personal hygiene and transfers. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0730 — pattern
    Observe 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 ensure annual performance reviews were completed for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) whose files were reviewed. This had potential to affect all residents who currently resided in the nursing home and who could receive care from these staff. Findings include: The following nursing assistants (NA)'s personnel records were reviewed for annual performance reviews and identified the following: NA-A was hired on 6/14/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. NA-F was hired on 11/7/23. NA-F's personnel record lacked evidence an annual performance review was ever completed. NA-B was hired on 7/16/18. NA-B's personnel record lacked evidence of a current annual performance review. NA-E was hired on 6/7/21. NA-E's personnel record lacked evidence an annual performance review was ever completed. During interview on 1/15/25 at 8:10 a.m., administrative support stated she did not have any performance reviews for staff in personnel files. She further stated there…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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 2 of 3 tub/shower rooms were maintained in good repair and sanitary conditions for 15 residents who utilized two tub/shower rooms on the Prairie unit. Finding include: Prairie Unit - East During an observation on 1/14/25 at 2:15 p.m., the tub/shower room on the east Prairie unit was observed to have a large tub and separate walk-in shower, toilet, and vanity with sink and cupboards. A furnace filter measuring approximately two feet by eight inches was observed laying on the floor half-way under the wall-mounted heater. The filter was heavily laden with gray fuzzy material. On top of the heater where air came out where small square grates that had an accumulation of dust and webs on them. Next to the heater was a corner wall where sheetrock was missing on the lower one - two feet. The material exposed resembled cement - white and porous, and was crumbling. These open areas were discolored rust and brown. A ceiling vent, approximately 12 inches x 12 inches was heavily laden with gray fuzzy debris with some of it 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 an annual performance review was conducted for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) and therefore failed to ensure annual training reflected the NA's areas of weaknesses identified on performance reviews. Findings Include: The following NA's personnel and training records were reviewed for annual performance reviews and training and identified the following: NA-A was hired on 6/14/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. NA-F was hired on 11/7/23. NA-F's personnel record lacked evidence an annual performance review was ever completed. NA-B was hired on 7/16/18. NA-B's personnel record lacked evidence of a current annual performance review. NA-E was hired on 6/7/21. NA-E's personnel record lacked evidence an annual performance review was ever completed. Review of online training transcripts for NA-A, NA-F, NA-B, and NA-E included online trainings on abuse prevention, behavioral health, workplace injury, cultural competency, dementia, dining and food…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-01-16 · tag F0641 — isolated
    Ensure 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, observation and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for pressure ulcers for 1 of 2 residents (R16) reviewed for pressure ulcers. Findings include: R16's admission MDS assessment dated [DATE], indicated R16 was admitted to the facility on [DATE], cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone); skin conditions indicated R16 was at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, had infection of the foot, other open lesion on the foot, surgical wounds; skin treatments included pressure reducing device for chair and bed, surgical wound care, application of ointments/medications other than to feet, application of dressings to feet. The MDS failed to indicate R16…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to develop a comprehensive person centered care plan to address falls and ensure the care plan was revised with the new fall interventions to prevent further falls for 1 of 2 residents (R79) reviewed for falls. Findings include: R79's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, dependent on staff for putting on/taking off footwear, sit to stand, chair/bed to chair transfer, toilet transfer, required substantial/maximal assistance with dressing, shower/bathe, personal hygiene, sit to lying, utilized a wheelchair, diagnoses included left femur fracture, non-Alzheimer's dementia, anxiety, depression, age related physical debility, and fall; fall in the last month, and a fracture related to a fall in the last six months, fall since admission or the prior assessment, two or more falls with no injury since admission. R79's care plan printed 1/14/25, indicated potential for injury r/t (related…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 residents received assistance with meals for 3 of 3 residents (R1, R2, and R10) reviewed for dining who requred staff assistance and/or supervison with meals. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate impaired cognition, no rejection of care, required setup assistance with eating, utilized a wheelchair, diagnoses included arthritis, dementia, and non-traumatic brain dysfunction. R1's care plan dated 1/3/25, indicated self care deficit related to dementia and intervention included eating: independent after setup. R2's significant change in condition MDS dated [DATE], indicated cognitively intact, required supervision with eating and dependent on staff for ADL's, diagnoses included anxiety, depression, and dysphagia (condition that makes it difficult to swallow). R2's care plan dated 10/22/24, indicated self care deficit and interventions eating: supervision, staff to monitor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to monitor weights as ordered for 1 of 1 resident (R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (R20 and R23) Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no rejection of care, substantial staff assistance with personal hygiene and diagnoses included coronary artery disease, hypertension, diabetes, non-traumatic brain dysfunction, dementia, Parkinson's disease (progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder. R10's care plan dated 11/20/24, indicated nutritional problem or potential nutritional problem r/t (related to) diabetic diet restrictions and current dx (diagnosis) of Parkinson's Disease, requires set up assist, high BMI (body mass index) and interventions included monitor weights. R10's provider order dated 1/10/25, nurse practitioner (NP)-H indicated daily weights update…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements) were completed for 2 of 2 residents (R16 and R20) reviewed for pressure ulcers. Findings include: R20's facesheet printed on 1/16/25, included diagnoses of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease. R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required moderate assistance with activities of daily living (ADL). R20 had no risk of pressure ulcers, no unhealed pressure ulcers and no current pressure ulcers. R20 walked with staff assistance. R20's physician orders dated 12/3/24, indicated skin check on every Tuesday in the afternoon. R20's care plan dated 12/5/24, indicated R20 had the potential for skin integrity impairment related to decreased baseline functional ability due to recent surgery and hospitalization.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 services to maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R20, R22) reviewed for restorative services. Findings include: R20's facesheet printed on 1/16/25, included diagnoses of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease. R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required moderate assistance with activities of daily living (ADL). R20 had no behaviors except rejection of care 1-3 days during MDS assessment period. R20 walked with staff assistance. R20's physician orders dated 11/27/24, indicated PT/OT (physical therapy/occupational therapy) for strengthening. R20's care plan dated 11/27/24, indicated R20 had a self-care deficient related to increased weakness from baseline due to recent hospitalization and surgery. R20's care plan goal was to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 conduct a comprehensive reassessment after falls to identify root cause and ensure new interventions were implemented to prevent further falls for 1 of 2 residents (R79) reviewed for falls. Finding include: R79's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, dependent on staff for putting on/taking off footwear, sit to stand, chair/bed to chair transfer, toilet transfer, required substantial/maximal assistance with dressing, shower/bathe, personal hygiene, sit to lying, utilized a wheelchair, diagnoses included left femur fracture, non-Alzheimer's dementia, anxiety, depression, age related physical debility, fall in the last month, and a fracture related to a fall in the last six months, fall since admission or the prior assessment, two or more falls with no injury since admission. R79's care plan printed 1/14/25, indicated potential for injury r/t (related to) impaired mobility due to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no rejection of care, required setup or clean up assistance with eating, substantial staff assistance with personal hygiene and diagnoses included non-traumatic brain dysfunction, dementia, Parkinson's disease(progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder, taking an antipsychotic. R10's care plan dated 11/20/24, indicated potential for drug interactions and adverse effects r/t (related to) polypharmacy interventions included administer medications as ordered, observe for effectiveness and adverse effects, update MD (medical doctor) PRN (as needed) monthly medication regime review by pharmacy consultant, forward…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure 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 and interview, the facility failed to ensure meals were served at a warm and palatable temperature to promote quality of life and nutritional intake for 2 of 2 residents (R22 and R16) reviewed for dining. This had the potential to affect all 25 residents who resided in the facility. Findings include: R22's facesheet printed on 1/16/25, included a diagnosis of amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrigsdisease (a progressive disease that weakens muscles and impacts physical function). R22's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was cognitively intact, had clear speech, could understand and be understood. R22 required substantial assistance or was dependent upon staff for activities of daily living (ADL) including eating. R22 did not walk independently. R22's physician orders dated 9/19/24, indicated a regular diet and assistance with eating meals. R22's care plan dated 9/18/24, indicated R22 had a potential nutritional problem…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0868 — isolated
    Have 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 document review and interview, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis. Findings include: Review of the QAPI meeting minutes and agenda identified QAPI meetings held 12/19/24, 7/11/24, 4/11/24. There was no additional documentation of a QAPI meeting provided between 7/11/24-12/19/24. On 1/16/25 at 1:14 p.m., the administrator stated she had worked at the facility approximately four weeks. The administrator stated she did not know if the facility had previously had a QAPI meeting between 7/11/24-12/19/24 , and confirmed she was not able to provide any documentation of any other meetings that had occurred. The administrator stated QAPI meetings were expected quarterly with attendance. The facility Quality Assurance and Performance Improvement (QAPI) policy dated 2/2024, indicated: The QAA committee will meet quarterly. QAPI activities and outcomes will be on the agenda of every staff meeting and shared with residents and family members through their respective councils and monthly newsletter. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure narcotic and controlled substances destruction was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft. Findings include: 10/2/24, 9:00 a. m. Review of narcotic books, Certificate of the Inventory and Destruction of Controlled Substances Form :Long Term Care Facilities, and Medication Disposition Log - Resident Record Identified 7 medication cards which contained 123 tablets of Oxycodone (narcotic pain medication), 11 cards which contained 175 tablets of lorazepam (controlled substance for anxiety), one card with 30 tablets of temazepam (controlled substance for insomnia), two cards with 36 tablets of pregabalin (controlled substance for nerve pain), two cards with 44 tablets of tramadol (opioid medication for pain) and one bottle of morphine with 14.5 milliliters (ml) remaining, were signed out of the narcotic books as destroyed, however, they were not documented on Destruction of Controlled Substances Form or the Medication Disposition Log - Resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 complete a thorough investigation when 1 of 1 residents (R1) alleged staff to resident abuse and the care plan was not reviewed to ensure all provisions of care were being adequately implemented. This put R1 at risk for future accidents when, during review, it was determined staff were not implementing transfer interventions as care planned. Findings include: A Facility Reported Incident (FRI) report, submitted to the State Agency (SA) on 4/30/24 at 2:00 p.m., indicated R1 had been picked up by alleged perpetrator (AP)/nursing assistant (NA-B) from the wheelchair and thrown into bed. A Facility Investigation 4/30/24, identified R1 reported to staff an allegation of abuse when NA-B picked her up from the wheelchair and threw her into bed. Report identified a police report was filed and, at that time, R1 denied there was abuse. AP was suspended during investigation and returned to work after education was completed on abuse. R1 was assessed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 implement Self Care plan interventions for 1 of 3 residents (R1) which put R1 at risk for falls during provisions of care. Findings include: R1's significant change Minimum Data Set (MDS), dated [DATE], identified R1 was dependent with sit to stand and chair/bed-to-chair transfers and did not make efforts to complete these activities. MDS indicated a diagnosis of hypertension, hyperlipidemia, hip fracture, stroke, seizure disorder, and malnutrition. R1 had a fall on 4/1/24 resulting in a right hip fracture. R1's Self Care plan, revised on 4/5/24, identified R1 was an assist of two, non-weight bearing on right leg for transfers, assist of one with wheelchair, non-weight bearing on right leg, and unable to ambulate in room at this time. Observations on 5/1/24 at 3:29 p.m., R1 was sitting at edge of the bed with wheelchair next to the bed. No transfer belt was observed in R1 room. During interview on 5/1/24 at 3:29 p.m., R1 stated NA-B had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-27 · tag F0851 — widespread
    Electronically 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, including information for salaried nursing staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed - Quarter 1, 2024, (October 1 - December 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The PBJ Staffing Data report indicated the following: 1) No RN Hours on 10/8/23, 12/23/23, 12/24/23, 12/30/23, and 12/31/23. 2) Failed to have Licensed Nursing Coverage 24 Hours/Day on 10/8/23, 11/5/23, 11/18/23, 11/25/23, 12/16/23, 12/23/23 and 12/24/23. During an interview on 3/26/24 at 10:05 a.m., together with the nursing staff scheduler (SS)-E reviewed nursing staff schedules for the dates identified on the PBJ report indicating No RN Hours and Failed to have licensed nursing coverage 24 hours a day. The paper schedules indicated RN coverage and licensed nursing staff coverage for each of the dates. During an interview on 3/26/24 at 10:58 a.m., 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview staff failed to ensure mechanical transfer lifts were cleaned after resident use for 2 of 2 residents (R19 and R20) observed for infection control practices. Findings Include: R19's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R19 was cognitively intact, dependent on staff for toileting, required set up or clean up assistance with personal hygiene, substantial/maximal assistance with transfers, and used a wheelchair for mobility. R19's care plan dated 3/22/24, indicated R19 had self-care deficit related to hx (history) of right hip fx (fracture) interventions included locomotion off unit: total dependence in w/c (wheelchair), toileting: assist of two to commode, transfer: assist of two resident performs stand pivot transfers with four wheeled walker and is able to take 3-5 steps as needed, and non-ambulatory. R19's progress note dated 2/27/24 at 10:54 p.m., registered nurse (RN)-A indicated R19 was followed by PT/OT (physical therapy/occupational therapy)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-27 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess for potential restraints for 2 of 2 residents (R12 and R20) who used weighted blankets. Findings include: R12's facesheet printed on 3/27/24, included diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting her right dominate side. R12's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R12 was cognitively intact, and required partial/moderate assistance with activities of daily living (ADL's). R12's physician orders did not include the use of a weighted blanket. R12's nursing assessments did not indicate R12 was assessed for safety with a weighted blanket. R12's care plan initiated on 10/23/23, did not include use of a weighted blanket. R12's measured weight was 210.5 pounds on 3/26/24. During an interview and observation on 3/25/24 at 1:48 p.m., R12 was observed resting on her back in her bed. A purple weighted blanket was observed over her. R12…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-02-24 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    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 resident mail was delivered on Saturdays for 7 of 7 residents (R1, R4, R5, R13, R15, R18, R20) reviewed during resident council. This deficient practice had the potential to affect all 21 residents residing in the facility. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment.R4's quarterly MDS dated [DATE], indicated no cognitive impairment.R5's admission MDS dated [DATE], indicated no cognitive impairment.R13's annual MDS dated [DATE], indicated no cognitive impairment.R15's annual MDS dated [DATE], indicated severe cognitive impairment.R18's quarterly MDS dated [DATE], indicated no cognitive impairment.R20's quarterly MDS dated [DATE], indicated no cognitive impairment.On 2/24/26 at 2:08 p.m., during resident council R1, R4, R5, R13, R15, R18, R20 attended and stated they did not receive mail on Saturdays and received the mail on Monday through Friday.On 2/24/26 at 2:31 p.m., activity…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,021 in federal fines across 1 penalty.

  • $8,021 — penalty dated 2024-10-03

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

Part of a chain

This home belongs to CURA — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 2 of 52.0≈ chain avg
The other 7 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CURAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 06/05/2023
DIRKES, MARKIndividualCORPORATE OFFICERsince 06/05/2023
OPATZ, TOMIndividualCORPORATE OFFICERsince 06/05/2023
STRUZYK, FREDIndividualCORPORATE OFFICERsince 06/05/2023
TF MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2023
CLUKA, MIRANDAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2024
KOENING, JONATHONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/08/2024
MOLITOR, DAVEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2025
STELTER, CAROLYNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2023

CMS files one row per role, so the 13 rows in the source record cover these 9 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.

$2.3M
Net patient revenuemost recent cost report
-19.2%
Operating marginrevenue minus expenses
$147K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 10%Other / private 25%

This home reported $147K 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

$551per resident / day
operating cost
$16,742per month
≈ monthly operating cost
$462per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245416. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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