Littlefork Care Center
912 Main Street, Littlefork, MN 56653 · Non profit - Corporation · 42 certified beds · (218) 278-6634 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $218,595 in federal fines (most recent 2025-02-20)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.5% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.2% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 5.8% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.2% | 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 | 5.0% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.3% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.7% | 12.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.7% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 41.0% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | 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.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 42 beds and averages 36.3 residents a day — about 86% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.83 hrs/resident/day on weekends vs 3.64 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.98 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · Lcited before2025-02-27 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement transmission-based precautions (TBP) for respiratory symptoms until confirmatory respiratory test results were obtained for 6 of 38 residents (R34, R31, R11,R22, R36, R32), failed to initiate droplet precautions for 1 of 6 residents (R31) known to test positive for influenza A, failed to implement strategies to mitigate the risk of an influenza outbreak, including initiating active surveillance of residents for signs and symptoms of influenza A, isolation of residents presenting with symptoms of influenza A, and post signage at the facility entrances to notify visitors of active illness in the facility. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility when 8 of 38 residents (R31, R11 , R36, R32, R38, R7, R35, R3) contracted influenza A. This resulted in an immediate jeopardy (IJ) which placed all 38 residents at a high likelihood for serious illness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-10 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to follow through on a grievance regarding staffing levels to complete baths for 4 of 4 (R14, R15, R21, R32) residents who voiced concerns during resident council. Findings include:R14's annual MDS dated [DATE], identified R14 was cognitively aware and was independent with activities of daily living. The ability to bathe was not assessed.R15' quarterly MDS dated [DATE], identified R15 was cognitively aware and was dependent on staff for toileting and required substantial/maximal assistance with bathing.R21's quarterly MDS dated [DATE], identified R21 was cognitively aware and required set up for personal hygiene and was dependent on staff for toileting. However, bathing was not assessed.R32's quarterly MDS dated [DATE], identified R32 was cognitively aware and was independent with activities of daily living. The ability to bathe was not assessed.During resident council on 12/9/25 at 1:14 p.m., R15, R21 and R32 all stated they were supposed to get more…
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 · E2025-12-10 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program with established protocols and monitoring to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 resident (R6) reviewed for antibiotic use. The lack of a program had potential to affect all 37 residents residing in the facility. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had no cognitive impairment and required maximal assistance with dressing, grooming, and was dependent with toileting. R6 had an indwelling foley catheter and was occasionally incontinent of bowel. Diagnoses included congestive heart failure, kidney disease, retention of urine and unspecified hydronephrosis. The monthly Infection Surveillance Report for October 2025, identified R6 was prescribed ceftriaxone (an antibiotic) one time per day for two days. Review of R6's medical record lacked evidence of any established criteria (i.e. McGeer)…
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 · D2025-12-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess potentially abusive behaviors and identify interventions to prevent abuse for 1 of 1 resident (R30) reviewed for abuse and involved R3. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R3's nursing progress note dated 12/5/25 at 6:46 p.m., identified a physical altercation with another patient at 6:20 p.m. R3 had his clothing protector pulled on repeatedly by another patient. R3 did appear to be alarmed while incident was happening as staff witnessed facial expression and fast paced breathing. R3 did not appear to have any marks left from clothing protector being pulled. R3 did not retaliate. R3 appeared to be calm at this time. Clothing protector removed. Other patient removed from vicinity. At 6:50 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail and administrator at 6:32 p.m.…
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 before2025-12-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to immediately report allegations of abuse to the state agency for 1 of 1 resident (R30) reviewed for abuse, who had an altercation with R3 Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R30's nursing progress note identified the following on 12/5/25: At 6:35 p.m., R30 grabbed R3 by the clothing protector and was jerking the clothing protector toward himself at 6:20 p.m. It did take several staff to remove R30 from the area and to get the clothing protector off R3. R30 did swing at staff and was yelling. R30 was in dining room in wheelchair dozing just prior to this incident. At 6:40 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail.…
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 before2025-12-10 · 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 conduct a thorough investigation of possible abuse for 1 of 2 resident (R30) reviewed for abuse who had an altercation with another resident (R3). Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R30's nursing progress note dated 12/5/25 identified the following: At 6:35 p.m., R30 grabbed R3 by the clothing protector and was jerking the clothing protector toward himself at 6:20 p.m. It did take several staff to remove R30 from the area and to get the clothing protector off R3. R30 did swing at staff and was yelling. R30 was in dining room in wheelchair dozing just prior to this incident. At 6:40 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail.…
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 · D2025-12-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance with toileting for 2 of 3 residents (R3, R30) reviewed for toileting. Findings include:R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required maximal assistance with transfers and bed mobility.R3'a Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R3 was always incontinent of bladder. He was often resistive to assistance with toileting tasks, had been noted on a couple occasions to have refused assistance to the toilet and urinated in the dining room. R3 had a yeasty rash in his groin, nystatin powder was being applied per standing house orders. R3 refused to let writer assess area. No other skin issues have been observed/reported.R3's care plan dated 10/20/25, identified R3 was incontinent of bowel and bladder and directed staff to check R3 every 2-3 hours to assist with toileting as needed.During a continuous…
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 before2025-12-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 2 of 3 residents (R3, R30) reviewed for pressure ulcers. R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and required maximal assistance with transfers and bed mobility. R3 was at risk for pressure injury/ulcer but did not have a current pressure injury/ulcer. R3's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 7/30/25, identified R3 had a Braden score of 16, indicating he was at mild risk for pressure ulcer/injury. R30 was always incontinent of bowel/bladder, usually resistive to allowing staff to perform peri cares and other hygiene tasks. R30 was able make changes in his position frequently and independently as he chose. R30 was ambulatory but gait was unsteady, a referral to physical therapy was made. R30 was using a wheelchair to move around the facility, had a pressure reducing mattress on his bed and a pressure reducing…
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 · D2025-12-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 1 resident (R30) reviewed for nutrition. Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and had diagnoses that included Alzheimer's disease, dementia and type 2 diabetes.R30's care plan revised 10/30/25, identified R30 had an ADL self-care performance deficit related to Alzheimer's disease, dementia and right/left knee pain. The care plan directed R30 was independent in eating. The care plan also identified R30 had a potential for weight loss related to his disease process. Staff were directed to monitor meal and snack intake, offer a bedtime snack per R30's routine: cottage cheese, yogurt, granola bar or cheese and crackers. R30 had a regular diet with regular texture and thin consistency. R30 was to be weighed weekly on bath days.R30's Mini Nutritional assessment dated [DATE],…
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 · D2025-12-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure as needed (PRN) medications were administered as prescribed for 1 of 1 resident (R12) observed to have lower extremity edema and weight gain. In addition, the facility failed to ensure medications were given per manufacturer instructions for 1 of 1 resident (R20) observed to receive insulin administration from a insulin flex pen during observations of medication pass in the facility. Findings include:R12R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition, and required moderate to maximal assistance with dressing and grooming. Diagnoses included acute on chronic congestive heart failure (CHF), diabetes, kidney disease and persistent atrial fibrillation. R12's Physician Progress Notes dated 10/2/25, identified R12 was seen by his primary provider on 10/2/25, during nursing home rounds. The provider identified R12 was recently admitted to the nursing home for congestive heart failure with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with the Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 2 of 2 residents (R6, R5) in the sample that were on EBP. In addition, the facility failed to establish a system to identify, investigate and control infections to prevent the spread of infection. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had no cognitive impairment and required maximal assistance with dressing, grooming, and was dependent with toileting. R6 had an indwelling foley catheter and was occasionally incontinent of bowel. Diagnoses included congestive heart failure, kidney disease, retention of urine and unspecified hydronephrosis. R6's care plan with revision date 2/14/25, identified R6 was on enhanced barrier precautions (EBP) due the presence of a urinary catheter and a goal to not acquire a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 22 citations
- Potential for harm · Dcited before2025-12-10 · 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 observation, interview, and document review, the facility failed to ensure pneumococcal immunizations were offered, addressed and/or provided in accordance with Centers for Disease Control (CDC) guidelines for 3 of 5 residents (R11, R23, R37) reviewed for immunizations.Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, the graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical…
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 · D2025-12-10 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 3 of 5 residents (R11, R23. R37) reviewed for immunizations.Findings include:R11's significant change Minimum Data Set (MDS) dated [DATE], identified an admission date of 10/30/25, and date of birth [DATE]. R11 had intact cognition and was independent with most activities of daily living (ADLs). Diagnoses included metabolic encephalopathy, and hypertension. R11's medical record was reviewed and lacked any immunization records or evidence R11 had been offered, educated on, or provided the CDC recommended COVID-19 immunization(s) since her admission to the nursing home several months prior. R23's discharge MDS dated [DATE], identified an admission date of 11/25/25, and date of birth [DATE]. R23 had intact cognition and required moderate to maximal assistance with most of his ADLs. Diagnoses included cirrhosis of the liver with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure timely reporting of an allegation of resident to resident abuse to the state agency (SA) for 2 of 2 residents (R1, R2) reviewed for abuse.Findings include:R1's admission Record indicated he admitted to the facility 1/10/25, with diagnosis that included neurocognitive disorder with [NAME] bodies, dementia with mood disturbance, agitation and psychotic disturbance.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed physical, verbal and other behaviors 1-3 days during the assessment period. The MDS indicated R1 ambulated independently.R1's care plan dated 5/22/25, identified a risk for harm to self or others. The care plan directed staff to approach R1 from the side when upset, hold hands gently when attempting to re-direct, and if he posed a potential threat to self or others, approach calmly and speak directly to him. The care plan further directed nursing to contact law…
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 · D2025-08-06 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 notice of intent to discharge for 1 of 1 residents (R1) who was sent to the hospital and discharged from the facility.Findings include:R1's admission Record indicated he admitted to the facility 1/10/25, with diagnosis that included neurocognitive disorder with [NAME] bodies, dementia with mood disturbance, agitation and psychotic disturbance.R1's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated he displayed physical, verbal and other behaviors 1-3 days during the assessment period. R1's care plan dated 5/22/25, identified a risk for harm to self or others. The care plan directed staff to approach R1 from the side when upset, hold hands gently when attempting to re-direct, and if he posed a potential threat to self or others, approach calmly and speak directly to him. The care plan further directed nursing to contact law enforcement to send to the emergency department (ED) when aggressive and not…
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 · E2025-02-27 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure use of an as-needed psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medications for 2 of 5 residents (R18,R22) reviewed for unnecessary medication use. In addition, the facility failed to complete comprehensive assessment and ongoing monitoring of behaviors for an administered antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use. Findings include: R18: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had a severe cognitive impairment and diagnoses that included Alzheimer's disease and dementia. R18 did not exhibit behaviors during the assessment period. R18's undated care plan, identified R18 used anti-anxiety medications (lorazepam) related to recent changes in health status. Interventions included: - Administer anti-anxiety medications as ordered by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · 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 timely notify the physician when a hematoma (localized collection of blood outside of blood vessels) was identified and subsequently opened requiring a new intervention for 1 of 2 (R18) residents reviewed for wound care. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and did not exhibit behaviors during the assessment period. Diagnoses included Alzheimer's disease and a methicillin-resistant staphylococcus aureus (MRSA) infection. R18 had an open lesion other than ulcers, rashes or cuts. No pressure, venous or arterial ulcers. R18's undated care plan, identified R18 had impaired skin integrity due to a tissue injury. Staff were directed to encourage R18 to elevate legs, R18 had an air mattress on my bed, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no signs of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the care plan was updated timely to to prevent falls for 1 of 1 residents (R19) reviewed for falls. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and osteoporosis. R18 had a fall without injury and a fall with injury. R18 did not use an alarm or any physical or electronic device that monitored R18's movement and alerted staff when movement was detected. R18's care plan revised 2/6/25, identified R18 was at risk for all related to confusion. Interventions included: - Assist R18 as needed with mobility and transfers - Be sure R18's call light was within reach and encourage R18 to use it for assistance as needed. - Bed in lowest position - Ensure that R18 was wearing appropriate footwear shoes when up ambulating or mobilizing in wheelchair and gripper socks when in bed. - R18 did not remember…
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 · D2025-02-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure 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 record review, the facility failed to ensure assistance was offered with meal setup to promote safety and independence with eating for 1 of 1 resident (R38) reviewed for activities of daily living (ADL) and needed set up and supervision to eat. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 had intact cognition and required supervision or touching assistance with eating, maximum assistance with dressing and grooming and was dependent on staff for toileting, and transfers. Diagnoses included hemiplegia following cardiovascular disease and venous insufficiency. R38's Occupational Therapy (OT) Evaluation dated 2/7/25, identified R38 required supervision with eating and assistance to cut up his food. R38's Speech-Language Pathology Evaluation dated 2/11/25 identified R38 was edentulous (without teeth) and had top and bottom dentures but chose not to wear them. R38 was admitted on a soft and bite sized diet. R38 reported he was not having…
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 · D2025-02-27 · 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 perform ongoing monitoring and wound care for an injury for 1 of 2 residents (R18) reviewed for wound care; and the facility failed to implement interventions for edema for 1 of 1 resident (R38) reviewed for edema. Findings include: R18: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and did not exhibit behaviors during the assessment period. Diagnoses included Alzheimer's disease and a methicillin-resistant staphylococcus aureus (MRSA) infection. R18 had an open lesion other than ulcers, rashes or cuts. No pressure, venous or arterial ulcers. R18's undated care plan, identified R18 had impaired skin integrity due to a tissue injury. Staff were directed to encourage R18 to elevate legs, R18 had an air mattress on my bed, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 2 residents (R4); and failed to follow pressure ulcer treatments as ordered to promote healing for 1 of 2 residents (R31) reviewed for pressure ulcers Findings include: R4: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact and had diagnoses that included peripheral neuropathy ( occurs when the nerves located outside of the brain and spinal cord are damaged. It often causes weakness, numbness, and pain, typically in the hands and feet, but can also affect other areas and body functions. It is common in people with diabetes.), type 2 diabetes, congestive heart failure (CHF), venous insufficiency (occurs when the valves in the veins become damaged, allowing blood to flow backward.), and dermatitis. R4 was at risk for pressure ulcer but had no open areas. R4's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 4/16/24, identified R4 was at risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · 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 comprehensively assess each fall to ensure interventions were followed; and failed to ensure fall interventions were care planned timely and implemented to prevent falls for 1 of 1 residents (R19) reviewed for falls. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and osteoporosis. R18 had a fall without injury and a fall with injury. R18 did not use an alarm or any physical or electronic device that monitored R18's movement and alerted staff when movement was detected. R18's Falls Care Area Assessment (CAA) dated 1/6/25, identified R18's fall risk was 27; Score 10 or higher indicated R18 was at high risk of falls. R18 was currently assistance of one staff for all transfers with the use of a mechanical lift. R18 was not able to walk, was using a manual wheelchair. R18 was able to move herself around…
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 · D2025-02-27 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess for trauma informed care and identify potential triggers, to avoid potential re-traumatization for 1 of 1 residents (R7) reviewed for trauma informed care. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and had diagnoses of post traumatic stress disorder (PTSD), anxiety, insomnia, and bipolar disorder (a mental illness characterized by extreme mood swings). R7's psychosocial well-being Care Area Assessment (CAA) dated 3/25/24, failed to identify an analysis and/or goal. R7's Social Services Quarterly Note dated 12/9/24, identified R7 had no change in status. R7 was currently receiving psychoactive medications and psychological/psychiatric services were currently indicated. R7's Behavior assessment dated [DATE], identified R7 became very upset with staff and aimed her anger toward one staff person, yelling at them, calling them names and refusing them to provide R7 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 dementia related behaviors and implement appropriate interventions to minimize verbal and physical resident to resident altercations for 1 of 2 residents (R22) reviewed for dementia care. Findings include: R22's admission Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and required supervision with activities of daily living (ADLs). R22 exhibited delusions, physical and verbal behaviors symptoms directed toward others daily, as well as other behavioral symptoms such as pacing, rummaging and verbal symptoms. R22's behavioral symptoms significantly impacted his care as well as put others at significant risk for physical injury, intruded on their privacy and disrupted care and living environments. R22 rejected care and wandered daily. Diagnoses included neurocognitive disorder with lewy bodies, and heart disease. R22's Behavior Care Area assessment dated [DATE], identified R22 had a diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were addressed and acted upon and documented in the medical record for 3 of 5 residents (R11, R22, R36) reviewed for unnecessary medication use. Findings include: R11: R11's admission Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment and diagnoses included Alzheimer's disease and malignant neoplasm of rectal sigmoid junction. R11's Order Summary Report dated 2/17/25, identified R11's current medication regimen with their corresponding start dates. This included an order for quetiapine (an antipsychotic) 25 mg one tablet at bedtime related to dementia with other behavioral disturbances with order date 11/26/24. R11's completed Consultant Pharmacist's Medication Review, dated December 2024, identified R11's medication regimen was reviewed and an irregularity was listed involving R11's medication quetiapine with related to the indication for the medication was listed as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · 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 offer pneumococcal vaccination according to Centers for Disease Control (CDC) guidelines for 1 of 5 residents (R36) reviewed for vaccinations. Findings include: R36's admission Minimum Data Set (MDS) dated [DATE], identified R36 was admitted to the facility on [DATE], was [AGE] years old, at had diagnoses including chronic lung disease, used tobacco, and had mild cognitive impairment. The assessment identified R36 was not up to date with pneumococcal vaccination and the vaccination was not offered on admission. The undated facility immunization report identified R36 had received the PPSV23 on 11/18/19, and PCV13 on 10/31/18. R36's electronic health record did not include evidence R36 or R36's representative were offered/received education regarding pneumococcal vaccine booster(s) such as the PCV15 or PCV20 in conjunction with their provider. On 2/27/25 at 2:57 p.m., registered nurse (RN)-A stated vaccines were discussed and offered upon admission. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · 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 perform a comprehensive assessment of falls to include root cause and failed to implement appropriate interventions to reduce the risk for falls from bed for 1 of 3 residents (R2) reviewed who had multiple falls from bed. Findings include: R2's admission Record indicated he admitted to the facility 5/6/24. R2's diagnosis included Alzheimer's disease, hemiplegia (severe or complete loss of movement function) and hemiparesis (mild to moderate weakness), dementia and insomnia. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated no hallucinations, delusions or behaviors were displayed. The MDS indicated R2 had upper and lower extremity impairments to one side and indicated he was independent with transfers and ambulation. R2's MDS indicated frequent bladder incontinence and occasional bowel incontinence and indicated he had two or more falls since the previous assessment. R2's care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to act on grievance filed for 1 of 3 residents (R1) reviewed who filed a grievance alleging verbal abuse by staff. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included cerebral palsy, post-traumatic stress disorder, bipolar disorder, and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicted she displayed verbal behaviors during the assessment period. The MDS indicated R1 was dependent on staff for toileting and transfers. R1's care plan dated 12/11/24, identified a behavior problem; requesting task from staff, then refusing when staff attempt to provide. The care plan always directed two staff in R1's room and indicated R1 was either elated or upset, would yell with cares, make false accusations of abuse by staff, and wanted instant gratification. The care plan directed staff to discuss behavior if reasonable, leave her alone to calm down when…
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 before2025-01-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to immediately report an allegation of abuse to the state agency, but no later than two hours, for 1 of 3 residents (R1) reviewed who alleged abuse from staff in the facility. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included cerebral palsy, post-traumatic stress disorder, bipolar disorder, and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicted she displayed verbal behaviors during the assessment period. The MDS indicated R1 was dependent on staff for toileting and transfers. R1's care plan dated 12/11/24, identified a behavior problem; requesting task from staff, then refusing when staff attempt to provide. The care plan always directed two staff in R1's room and indicated R1 was either elated or upset, would yell with cares, make false accusations of abuse by staff, and wanted instant gratification. The care plan directed staff to discuss…
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 before2025-01-23 · 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 investigate an allegation of abuse for 1 of 3 residents (R1) reviewed when R1 reported an allegation of abuse. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included cerebral palsy, post-traumatic stress disorder, bipolar disorder, and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicted she displayed verbal behaviors during the assessment period. The MDS indicated R1 was dependent on staff for toileting and transfers. R1's care plan dated 12/11/24, identified a behavior problem; requesting task from staff, then refusing when staff attempted to provide. The care plan directed two staff at all times in R1's room and indicated R1 was either elated or upset, would yell with cares, make false accusations of abuse by staff, and wanted instant gratification. The care plan directed staff to discuss behavior if reasonable, leave her alone to calm down…
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 before2024-09-26 · 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 comprehensively assess for removing and placing a Wander Guard (WG- alarming device) and ensure the fenced in area for residents was secure for 1 of 3 residents (R1) reviewed for resident safety. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, wandering behaviors occurred daily, verbally expresses needs to staff, independent with walking, wander/elopement alarm was used daily. R1's elopement risk assessment dated [DATE], indicated R1 was at risk for wandering/elopement from facility. Wander guard (WG) was in place. R1's care plan dated 7/11/24, identified R1 being at risk for elopement due to cognitive status as he was exit seeking, wander guard was placed and regular facility checks were to be completed. A report to the State Agency (SA) dated 9/17/24, indicated on 9/17/24, staff received an alert from a citizen R1 was walking outside on the facility grounds. R1…
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 · C2025-02-27 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the state agency (SA) survey results were available for residents voiced by 2 of 3 residents (R4, R25) who attended resident council meetings. In addition, the facility failed to ensure the most recent SA survey results were readily accessible at all times. This had the potential to affect all 38 residents and families that may wish to review the results. Findings include: R4's quarterly Minumum Data Set (MDS) dated [DATE], indentified R4 was cognitively intact. R25's annual MDS dated [DATE], indentified R25 was cognitively intact. During the resdient council meeting on 2/25/25 at 2:27 p.m., R4 and R25 were in attendance. Both residents stated they regularily attended resident council meetings. R4 and R25 were aware the SA survey results were to be available, although did not know where the results were located. During observation on 2/25/25 at 2:04 p.m., there was a binder hanging on the wall across from the nurses station near…
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 · C2025-02-27 · 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 ensure a posting was updated daily and ensure the census was on the nurse staff posting. This had the potential to effect all 38 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation on 2/21/25 at 1:06 p.m., the facility nurse staff posting was on the wall near the front entrance. The nurse staff posting was dated 2/21/25, indicated a census of 38 and included information on scheduled shifts for nursing staff along with the number of staff assigned to the shift with total hours worked. During an observation on 2/25/25 at 3:17 p.m., the nurse staff posting continued to be dated 2/21/25. The director of nursing (DON) stated she did not know who was responsible to complete, update and post the nurse staff posting. The nurse staff postings were reviewed from 1/19/25 through 2/25/25. The nurse staff postings were not updated with actual working staff hours on the following 12 days: 1/19/25, 1/20/25, 1/23/25, 1/24/25, 2/1/25, 2/2/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$218,595 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $218,595 — penalty dated 2025-02-20
- Medicare payment denial — starting 2025-03-27 for 47 days
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 ST. FRANCIS HEALTH SERVICES — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 4.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 13 homes this chain runs (chain average 2.8★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| DRIPPS, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| EHLERS, DOUGLAS | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| GOODNOUGH, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| GRAMM, TIMOTHY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2023 |
| LAIR, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LIENEMANN, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LUETMER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO DATE PROVIDED |
| NELSON, PATRICK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| RENTZ, LAURA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| SCHNEIDER, TODD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2013 |
| WIESE, LORRAINE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/25/2017 |
| BACH, CURTIS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2024 |
| PETERSON-DEVRIES, CAMI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2022 |
| RAW, CAROL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/16/2005 |
| EIDE BAILLY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2023 |
| INTERNATIONAL FALLS MEMORIAL HOSPITAL ASSOCIATION | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2016 |
| ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2016 |
| BURROWS, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2024 |
| CASPERS, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/29/2014 |
| COPEMAN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| FAIRCHILD, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/07/2006 |
| GRASHORN, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| HANNEKEN, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/20/2022 |
| HEJHAL, ROXANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2023 |
| HELL, TAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/09/2025 |
| HOFMANN, REED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2023 |
| HOHENSTEIN, CINDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/30/2025 |
| MARLOW, JINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/06/2022 |
| MCCLEERY, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| NASH, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/28/2025 |
| NUTHAK, CATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/18/2009 |
| RENTZ, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/22/2024 |
| RYAN, BEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/27/2012 |
| RYAN, GEOFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/12/1998 |
| STOCK, KELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2022 |
| THOMPSON, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/10/2018 |
| TOMOSON, APRIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/12/2021 |
| WALKER, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2024 |
| TOMCZAK, CINDY | Individual | ADP OF THE SNF | since 06/15/2023 |
CMS files one row per role, so the 104 rows in the source record cover these 39 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 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 $202K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245542. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-10, 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.