Meeker Manor Rehablitation Center, LLC
600 South Davis Avenue, Litchfield, MN 55355 · For profit - Limited Liability company · 65 certified beds · (320) 693-2472 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding 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 $14,696 in federal fines (most recent 2024-03-06)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (63%) 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
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 | 15.9% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.7% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.0% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 35.3% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.1% | 12.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 5.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.2% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.5% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 69.7% | 82.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.7% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 14.8% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.9% 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 37 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% 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 | 49.4%CMS range 37.3–63.1 | 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 | 10.2%CMS range 6.9–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 64.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 89.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 89.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.0–14.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 65 beds and averages 50.4 residents a day — about 78% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.68 on weekdays — 14% thinner on weekends. RN hours go from 0.65 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2024-03-06 · 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 identify heat register as safety hazard for 1 of 1 resident's (R1) bed that was too close to the heat who had a history of sleeping with his legs off the bed. This deficient practice resulted in an immediate jeopardy (IJ) for R1. The IJ began on 3/1/24, when the facility failed to ensure R1's bed was a safe distance from the heat source, R1 was found with is left foot on top of the heater which resulted in multiple second degree burns to the foot and required admission to hospital burn unit for treatment. The administrator and director of nursing (DON) were notified of the IJ on 3/6/24 at 4:51 p.m. The facility implemented corrective action and the deficient practice was corrected on 3/1/24, prior to the survey and was issued at past non-compliance. Findings include: Second degree burn: is also called partial thickness burn. These burns involve the outer layer of skin (epidermis). They can extend to the middle skin layer (dermis). Second…
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 before2026-05-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an interdisciplinary team (IDT) assessment was completed to determine whether self-administration of medication was clinically appropriate and safe prior to permitting self-administration of nebulizer treatments, for 1 of 1 resident (R1) reviewed for self-administration of medications.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear), and depression (a mood…
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 · D2026-05-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receiving psychotropic medications were adequately assessed and monitored. Further the facility failed to initiate target behavior monitoring for 1 of 5 residents (R3) reviewed for unnecessary psychotropic medications.Findings include:R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required assistance with activities of daily living (ADL's). R3's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by injury), unspecified dementia without behavioral, psychological, mood, or anxiety disturbances (decline in memory and thinking abilities), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (a condition involving excessive worry or fear), and mood affective disorder (a mental health condition affecting mood and emotional state). The MDS further identified R3 received antipsychotic, antidepressant,…
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 before2026-05-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans to address significant medical conditions and medication-related risks, including failure to care plan anticoagulant therapy for 2 of 2 residents (R1 and R3) reviewed for anticoagulant medications, and failure to care plan cardiac conditions, pacemaker presence, and condom catheter use for 1 of 2 residents (R1) reviewed for cardiac care needs.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate…
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 · D2026-05-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received routine bathing and grooming services necessary to maintain personal hygiene and dignity, including failure to provide scheduled weekly bathing and failure to assist with facial hair grooming for 2 of 6 residents (R2 and R21) reviewed for activities of daily living (ADL) care.Findings include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had intact cognition and required assistance with activities of daily living (ADL)'s. R2's diagnoses included primary generalized osteoarthritis, atrial fibrillation, urinary tract infection (last 30 days), thyroid disorder, depression, chronic pain syndrome, urge incontinence, suicidal ideations, and weakness.R2's care plan printed 5/19/26, identified a self-care deficit related to falls. The care plan identified interventions and goals which included R2 would accept assistance with self-cares and would be dressed, groomed, and bathed per preferences.…
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 · D2026-05-20 · 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 interview and record review, the facility failed to ensure appropriate care and services were provided for the management of an external urinary catheter system, including failure to obtain physician orders and implement care instructions for cleaning, disinfecting, and changing the condom catheter drainage bag for 1 of 1 resident (R1) reviewed for urinary catheter care.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to clarify R5's oxygen (O2) order, reconcile the O2 order, and administer O2 as ordered for 1 of 1 (R5) resident reviewed for oxygen therapy. Findings include: Review of State Agency (SA) report, dated 9/21/25 at 7:17 p.m., identified R5's family member noticed an oxygen tank in R5's room that was not in use since their admission to the facility. R5's undated, current Minimum Data Set (MDS) list identified R5 was admitted [DATE] with diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). R5's 9/19/25, Orders Discharge Report identified R5 was to take oxygen (O2) 2 liters (L) by inhalation route at bedtime. R5's 9/19/25, Admission/Initial Data Collection assessment sheet identified in the respiratory status section related to oxygen needs was left blank. R5's 9/19/25, 48-Hour Care Plan identified R5 had an alteration in oxygen/gas exchange. The goal was to have adequate gas exchange with no cyanosis (bluish discoloration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure adequate supply of medication was obtained and administered as ordered for 1 of 3 sampled residents (R1) reviewed for pharmacy services.Findings include: Review of State Agency (SA) report on 9/15/25 at 8:30 a.m., identified the facility had not inform R1's family member that R1 did not receive her antibiotics and had missed 2 of 4 doses and nursing staff did not have access to retrieve emergency medications. R1's 8/25/25, Hospitalist Progress note identified R1 had a fall and obtained a hip fracture. On 9/2/25, while hospitalized R1 obtained a fever of 102 degrees (Fahrenheit). On 9/06/25, R1 had loose stools and was tested positive for clostridium difficile (C diff) (bacteria in the gut that causes severe diarrhea) on 9/06/25. R1's labs identified elevated white blood cell count (WBC) of 20.9. Vancomycin therapy was to start for R1's infection on 9/06/25 and had orders to continue administration of antibiotic therapy on R1's discharge summary. R1's September 2025, Medication Administration Record (MAR)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · tag F0725 — failed to have enough nursing staff — isolatedProvide 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 the care and assistance they needed in a timely manner for 3 of 4 residents (R1, R2, R4) reviewed for staffing. Findings include: R1 R1's Minimum Data Set (MDS) admission assessment dated [DATE], identified R1 had intact cognition, no rejection of cares, and no behaviors. R1 required staff assist with dressing, bed mobility, transfers, and toileting. R1 was frequently incontinent of bowel and urine and had pain almost constantly and received scheduled and as needed pain medication. R1's diagnoses included rheumatoid arthritis (a chronic inflammatory condition that primarily affect the joints, causing pain, swelling and stiffness), anxiety, depression, pressure ulcer of left buttock, and polyneuropathy (disorder that damages the nerves and causes weakness, numbness, and burning pain). R1 also has one stage four pressure ulcer (extends into muscle, tendon, and ligaments, and can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-03 · 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 document review, interview and observation, the facility failed to implement proper infection control when two nursing assistants were observed not following enhanced barrier precautions or hand hygiene during direct care for 3 of 5 (R2, R4, R5) residents reviewed for infection prevention.Findings include:Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be infected with multi-drug resistant organisms as well as those at increased risk of multi-drug resistant organism acquisition (residents with wounds or indwelling medical devices)R2's face sheet dated 11/3/25, indicated R2 was admitted [DATE] and had diagnoses of type II diabetes, mood disorder due to known physiological condition with depressive features and obesity.R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired and had behavioral symptoms directed towards others. She was dependent on staff for all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to include the resident representative in development and implementation of the plan of care for one of one residents (R1) reviewed for residents rights.R1's quarterly minimum data set (MDS) dated [DATE], included R1 had moderate cognitive impairment and diagnoses of traumatic brain injury, stroke, and hemiplegia and hemiparesis (weakness or partial paralysis on one side of the body).R1's face sheet dated 8/28/25, included a contact for family member (FM)-A with the contact type of A/R Responsible Party and POA (power of attorney) Care.On 8/27/25 at 1:10 p.m., R1 was observed sitting in her power wheelchair with feet resting uncovered. Bilateral great toes (both big toes) were noted to have dark red, scab like appearance at base of toenail. No redness or drainage noted.R1's In-House Senior Services Consent form signed 4/16/21, included R1 would consent to podiatry in house.Provider order dated 7/30/25, included an order for a podiatry…
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 18 citations
- Potential for harm · D2025-05-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide timely notification to a provider for a change in condition related to low blood pressures for 1 of 1 resident (R2) who received dialysis and was already hypotensive. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus, and depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis and alteration in oxygen/gas exchange, respiratory status directed staff to keep medical doctor informed of changes. R2's physicians orders dated 3/28/25, indicated to take vital signs after dialysis one time a day every Monday, Wednesday and Friday. Review of R2's blood pressures indicated the following from 4/01/25 to 5/01/25: 5/01/25- 96/56 4/30/25- 76/43 4/29/25- 93/56 4/22/25 -107/67 4/18/25- 111/69 4/17/25- 109/67 4/16/25-112/69 4/15/25-101/60 4/13/25- 111/67 4/11/25-107/96 4/10/25-92/56…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · 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 report to the state agency (SA) for 3 of 3 residents (R3, R5 and R6) reviewed when R3, R5, R6 were named in an external complaint of alleged abuse by facility staff and no report was made within two hours. Findings include R3 face sheet, undated, indicated R3 diagnoses of unspecified dementia with anxiety, hypertension, diabetes, chronic obstructive pulmonary disease. R5 face sheet, undated, indicated R4 diagnoses of unspecified dementia, cognitive communication deficit, post-traumatic stress disorder, anxiety, Parkinson's disease. R6 face sheet, undated, indicated R5 diagnoses of hemiplegia and hemiparesis, epilepsy, adjustment disorder with disturbance of conduct, major depressive disorder, anxiety, traumatic subarachnoid hemorrhage with loss of consciousness. Facility was sent an anonymous email dated 4/28/25 at 9:04 a.m., which indicated .residents are getting neglected and abused daily, wounds are not getting completed. TMAs (trained medication aides) are doing insulin sticks, charting nursing assignments. TMAs are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 interview and document review the facility failed to thoroughly investigate and protect residents for an allegation of abuse for 3 of 3 residents (R3, R5 and R6) when the facility received an external, anonymous email alleging allegations of abuse by facility staff. Findings include: R3 minimum data set (MDS) dated [DATE], indicated moderately impaired cognition and displayed verbal behavioral symptoms toward others. R5 MDS dated [DATE], indicated moderately impaired cognition and no behavioral symptoms. R6 MDS dated [DATE], indicated cognition intact and was social isolated at times. Facility was sent an anonymous email dated 4/28/25 at 9:04 a.m., which indicated .residents are getting neglected and abused daily, wounds are not getting completed. TMAs (trained medication aides) are doing insulin sticks, charting nursing assignments. TMAs are also changing residents catherer [sic] and placing a new catherer [sic] not just the bag on NOC (nocturnal) shift. No showers are getting completed. [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 · D2025-05-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide needed care and services to 3 of 3 residents (R2, R4, R5) whose changes in health status were not adequately assessed and physician's orders and treatments were not administered. Findings include: Physician Orders and Lab Draws R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus and depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis and alteration in oxygen/gas exchange, respiratory status staff were instructed to keep medical doctor informed of changes. R2's Hospital Discharge Orders dated 3/26/25, indicated diabetic diet, no need to follow a low salt diet, eating salt would be good (no fluid restriction was ordered). R2's physicians orders dated 3/28/25, indicated to take vital signs after dialysis one time a day every Monday, Wednesday, and Friday. A Provider Rounding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed ensure ongoing commuication and collaboration with dialysis services for 1 of 1 resident (R2) who had orders not implemented. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus and had depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis will attend dialysis and will have no uncontrolled bleeding from fistula, shunt, or central line. The care plan directed staff to ask resident how she feels about doing dialysis, communicate with dialysis social worker as needed, for uncontrolled bleeding call 911, treatment and dressing change per protocol to dialysis site per MD order, send communication sheet folder to dialysis with each run, fluid restriction per order. In addition, the Care Plan indicated and alteration in oxygen/gas exchange, respiratory status staff were instructed to keep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures for 1 of 1 dishwasher observed. The facility also failed to consistently date fresh and frozen items at the time they are opened, or placed into a container, and failed to remove items which were beyond the acceptable date of use from the refrigerator. The facility failed to consistently verify temperatures were within the desired range in the refrigerators and freezers to assure food integrity. In addition, food temperature monitoring lacked consistency of completion following food preparation and prior to serving. This had the potential to affect all 50 current residents, as well as staff and visitors, who ate food served from the kitchen. Findings include: Dishwashing Temperature Monitoring: On 3/3/25 at 12:08 p.m., dietary aide (DA)-A was observed as she was finishing up in the dish room and was transitioning to meal service. DA-A stated the desired temperature was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-06 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to identify presence of over the counter medications in resident room for 1 of 1 residents (R30) observed to have medications in their room. The medication lacked orders from the medical provider for use, as well as assessment for proper storage and and self administration of medication. In addition, the facility failed to ensure an assessment was completed to determine safe medication administration for 1 of 1 resident (R15) observed to self administer medication through a nebulizer (breathing treatment). Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R30 was cognitively intact, and required assistance with performance of activities of daily living (ADL's). R30's diagnoses included anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), heart failure (a chronic condition where the blood doesn't pump blood effectively), hypertension (high blood pressure), end stage renal disease (a chronic kidney…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-06 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to address resident requests for further therapy evaluation for 3 of 3 residents (R30, R1, and R212) reviewed for choices. Findings include: R30: R30's Quarterly Minimum Data set (MDS) dated [DATE], indicated R30 was cognitively intact, and required assistance with performance of activities of daily living (ADL's). The MDS indicated there were no concerns regarding mood and behavior. The MDS identified R30 had intact cognition. R30's diagnoses included anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), heart failure (a chronic condition where the blood doesn't pump blood effectively), hypertension (high blood pressure), end stage renal disease (a chronic kidney disease where the kidneys lose their ability to filter waste and excess fluids from the blood), venous insufficiency (a disease of the veins in the legs which causes blood to pool in the legs), diabetes mellitus (a group of diseases that affects how…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to meet the oral health needs for 1 of 1 resident (R5) reviewed for routine dental services. R5's quarterly Minimum Data Set (MDS) dated [DATE], identified an admission date of 10/22/24, R5 had intact cognition, diagnoses of heart failure, chronic kidney disease and limitation of activities of daily living due to disability. R5's oral/dental evaluation dated 1/21/25, identified R5's teeth were observed to have plaque or debris in localized areas between teeth with several teeth missing and staff would assist with setting up dental appointments and transportation. During observation on 3/3/25 at 2:56 p.m., R5's teeth had a significant amount of built up white/grey debris on her front teeth and several missing teeth on her upper left side. R5 denied pain or difficulty with eating. R5 stated she could brush her own teeth with staff assistance for set up of her toothbrush and toothpaste at the sink. R5 stated she didn't remember when she last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to maintain sanitary conditions for mechanical lifts for 6 of 6 residents (R35, R47, R9, R27, R3, R2) who used a mechanical lift for transfers. This had the potential to affect other residents who used a mechanical lift for transfers. In addition, the facility failed to ensure hand hygiene while providing personal cares to prevent the spread of infections for 2 of 2 residents (R3, R9) observed during personal cares. Findings include: Mechanical lifts: During an observation on 3/4/25 at 10:19 a.m., nursing assistant (NA)-D wheeled R35 into his room and brought in the Hoyer lift (a mechanical lift to lift a person who is non-weight bearing for transfers). Clinical coordinator (CC)-A went to R35's room and applied a gown and gloves as R25 was on enhanced barrier precautions (Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). NA-D also applied a gown 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 · Dcited before2025-03-06 · 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 1 of 5 residents (R5) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 11/21/24, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult who had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer, after 5 years, the Pneumococcal 20-valent Conjugate Vaccine (PCV20) or Pneumococcal 21-valent Conjugate Vaccine (PCV21) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. This also identified an adult over [AGE] years old, who received one dose of PPSV23 at any age…
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 before2024-02-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to provide access to sweetener for meals in accordance with resident's wishes for 1 of 1 residents (R3) reviewed for choices. Findings include: R3's admission report printed 1/1/24, included diagnoses of body mass index 70 or greater, type 2 diabetes, difficult in walking, major depressive disorder, and weakness. R3's care plan dated 1/25/24, included resident was obese and required therapeutic diet related to type 2 diabetes. Interventions included provide resident with four packets of sugar instead of 16 packets requested. Facility failed to mention limitations to sugar substitute restrictions. During interview on 1/29/24 at 12:29 p.m., R3 stated she requested 6 yellow sugar substitute packets with each meal and staff would only provide her with 4. R3 voiced feeling upset and bothered by staff denying her additional sugar substitute packets. During interview on 2/1/24 at 12:02 p.m., social services (SS)-A stated attempts were made to honor food related requests. If facility was unable to accommodate request,…
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 · D2024-02-01 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 provide diabetic wound care as ordered for 1 of 2 residents (R36) reviewed for pressure ulcers. Findings include: R36's admission record printed 1/1/24, included diagnoses of type 2 diabetes with foot ulcer, disorder of vein, methicillin resistant staphylococcus aureus infection (MRSA-an infection resistant to certain antibiotics), and pressure ulcer on left heel. R36's after visit summary from dated 1/29/24, included wound care orders to paint eschar with betadine and let dry, cover with dry gauze, secure with rolled gauze and tape, change daily. For right toes: apply Aquacel AG between toes, change daily. For right great toe and top of first toe: apply Aquacel AG to open wound, cover with dry gauze, secure with rolled gauze and tape, change daily. On 1/31/24 at 10:58 a.m., licensed practical nurse (LPN)-A completed R36's wound care. LPN-A reviewed wound care orders, gathered supplies, applied PPE. LPN-A removed old dressing, placed soiled dressing on the bed, and cleaned wounds as ordered. Soiled gloves…
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 before2024-02-01 · 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
Based on observation, interview, and document review, the facility failed to follow proper infection control practices during diabetic wound care for 1 of 2 residents (R36) reviewed for wound care. Findings include: R36's admission record printed 1/1/24, included diagnoses of type 2 diabetes with foot ulcer, disorder of vein, methicillin resistant staphylococcus aureus infection (MRSA) (an infection resistant to certain antibiotics), and pressure ulcer on left heel. R36's after visit summary dated 1/29/24, included wound care orders to paint eschar with betadine and let dry, cover with dry gauze, secure with rolled gauze and tape, change daily. For right toes: apply Aquacel AG between toes, change daily. For right great toe and 1st top of first toe: apply Aquacel AG to open wound, cover with dry gauze, secure with rolled gauze and tape, change daily. On 1/31/24 at 10:58 a.m., licensed practical nurse (LPN)-A completed R36's wound care. LPN-A reviewed wound care orders, gathered supplies, and applied personal protective equipment (PPE). LPN-A removed soiled dressing, and placed 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 · Dcited before2024-02-01 · 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 1 of 5 residents (R3) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Center for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R3's admission report printed 1/1/24, indicated an age of 63 and included diagnoses of body mass index 70 or greater, type 2 diabetes, difficult in walking,…
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 before2023-11-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a comprehensive and individualized care plan was implemented for 1 of 2 residents (R2) reviewed for falls. Findings include: R2's quarterly MDS dated [DATE], indicated R2 was cognitively impaired and had dementia. The MDS further indicated R2 required assist with transfers and bed mobility and had two or more falls since admission or last assessment with no injury and used wheelchair for mobility. R2's Care Plan revised on 10/03/23, indicated offer to go to bed after supper, offer to lay resident down in recliner after lunch and to place foot pedals on the back of chair in a bag, to be used upon pushing resident in wheelchair and drop back cushion in wheelchair. R2's [NAME] dated 11/02/34, indicated transfer with assist of one with belt and two wheeled walker for transfers and place foot pedals on back of chair in a bag, to be used upon pushing resident in wheelchair. Drop back seat cushion in wheelchair. A Incident Report dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2025-03-06 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to consistently post the current daily nurse staff posting. This had the potential to affect all 50 current residents, their families and visitors. Findings include: During observation on 3/3/25 at approximately 11:00 a.m., the facility nurse staff posting was posted on the wall next to the office receptionist desk at approximately three feet from the floor. The posting included the date, direct care nursing staff shifts, numbers, total hours worked, and daily census. The nurse staff posting document was dated 2/27/25. The document behind the 2/27/25 document was dated 2/26/25. The staff posting documents for 2/27/25, 2/28/25, 3/1/25, 3/2/25, and 3/3/25 were lacking. On 3/5/25 at 1:03 p.m., staffing coordinator (SC) stated it was her responsibility to post the staff posting on Mondays through Friday. SC stated no one posted the information on the weekends. SC stated she updated the posting on Monday upon her return. SC stated the information posted on the staff posting was important to allow the staff,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-02-01 · tag F0732 — widespreadPost nurse staffing information every day.
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 consistently include the facility census on the daily nurse staff posting. This had the potential to affect all 51 current residents, their families, and visitors. Findings include: On 1/29/24 at 11:37 a.m., during the survey entrance conference the administrator stated the current census was 53. The administrator and Director of Nursing (DON) indicated there were two anticipated discharges planned for that day. On 1/29/24 at 7:34 p.m., the staff posting for [NAME] Manor, dated 1/29/24, indicated the facility census was 53. Throughout the course of the survey, 1/29/24 through 2/1/24, the census posting was noted to remain constant, with the census listed at 53. During interview on 2/1/24 at 2:32 p.m., Administrator identified the census posting was to be current and up to date to accurately reflect the current census in the building. The Administrator identified the person reponisble for the staff posting and census was new in their role…
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
$14,696 in federal fines across 1 penalty.
- $14,696 — penalty dated 2024-03-06
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 MONARCH HEALTHCARE MANAGEMENT — 45 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 3.7 | -1.7 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 44 homes this chain runs (chain average 2.2★, per CMS)
Showing 40 of 44; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HML LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 07/01/2016 |
| NIJ LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 14% | since 07/01/2016 |
| SPARTAN HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 23% | since 07/01/2016 |
| YAZOMA HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 23% | since 07/01/2016 |
| AREM, JEFFREY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 14% | since 07/01/2016 |
| STERN, WILLIAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 15% | since 07/01/2016 |
| HALPERT, MARC | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 23% | since 07/01/2016 |
| JAFFA, NOAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 14% | since 07/01/2016 |
| LEGUM, JOSHUA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 23% | since 07/01/2016 |
| MUENCZ, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | since 07/01/2016 |
| MONARCH HEALTHCARE OPERATING IV LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2016 |
CMS files one row per role, so the 14 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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 $961K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245361. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, 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.