Mn Veterans Home-Luverne
1300 North Kniss Avenue, Luverne, MN 56156 · Government - State · 85 certified beds · (507) 283-6200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2024
- 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 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
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 21.9% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.7% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.3% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.2% | 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 | 3.0% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.4% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 4.0% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.3% | 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 | 25.7% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.9% | 17.1% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.38 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.50 | 1.90 | 1.80 | 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 85 beds and averages 60.1 residents a day — about 71% occupied, or roughly 25 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 5.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.10 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.72 hrs/resident/day on weekends vs 5.45 on weekdays — 13% thinner on weekends. RN hours go from 1.73 to 1.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below 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.
10 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2026-01-14 · 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 interview and document review, the facility failed to provide safe transfer for 1 of 1 resident (R1) who required the use of a mobility van mechanical lift. This resulted in actual harm when R1 fell from the mobility van to the ground which resulted in significant ongoing pain, administration of pain narcotics and a decrease in activities of daily living (ADL)s. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, no behaviors, and no rejection of cares. R1 required staff assist with dressing, personal hygiene, and transferring. R1 required a manual wheelchair but was independent with mobility. R1's diagnoses included heart failure, arthritis, aphasia (language disorder that affects how you communicate), hemiplegia (paralysis on one side of body), and seizure disorder. R1 denied having pain but did receive scheduled pain…
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 · D2026-07-01 · 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 interview and document review, the facility failed to ensure a change of condition was identified and assessed by a nurse to determine what, if any, additional intervention maybe needed for 1 of 2 residents (R1) reviewed. R1 developed audible gurgling and potential respiratory impairment on [DATE] in the mid-afternoon which was not comprehensively assessed by a nurse until several hours later. Findings include: On [DATE] at 11:46 a.m., an interview was held with emergency medical technician (EMT)-E who stated they were on a crew that responded to the care center for R1 on [DATE], with reported respiratory distress. They arrived and found R1 lying in bed and very clearly in respiratory distress. The staff members present reported R1's condition onset about 2:00 p.m., which EMT-E then questioned aloud, Why did it take eight hours [to call]!? R1 had just had oxygen placed via cannula at 2 liters per minute (LPM) as EMT arrived and R1's oxygen saturations were poor when they checked them. EMT-E stated 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.
- Potential for harm · F2024-12-04 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide 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 1 of 1 narcotic emergency kit (E-Kit) was replaced prior to the pharmacy date of expiration documented on top of kit. This had the potential to affect all residents. Findings include: Observation on [DATE] at 4:40 p.m. with registered nurse (RN)-A of the [NAME] Wing medication room, identified the narcotic E-Kit, with a red numbered tag lock, and a bright green pharmacy sticker which listed the expiration date of [DATE]. The label directed to notify pharmacy 7 days prior to this date for replacement. Interview on [DATE] at 4:42 p.m. with RN-A reported the narcotic E-Kit was checked during each shift narcotic count, but there was no individual log signed that the E-kit had been checked and verified the medication had not expired. She reported the only documentation that the count was accurate was in the narcotic book that was signed by both the on-coming and off-going staff members. RN-A reported the expiration sticker should have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1), was free from potential misappropriation of property and/or potential drug diversion of ordered narcotic pain medication. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his findings. RN-B and RN-C reviewed the narcotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · 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
Based on interview and record review, the facility failed to report to the law enforcement a suspicion of potential drug diversion and failed to notify the Board of Nursing for 1 of 1 nurse (licensed practical nurse (LPN)-A) whose employment was terminated. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · 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
Based on interview and record review, the facility failed to compete a thorough investigation when it was reported a potential misappropriation of resident property/potential drug diversion had occurred. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) and the 5-day investigation identified LPN-C had found a green tote containing medication including narcotics had been left by the delivery driver inside one of the doors at the facility unattended. LPN-C retrieved the bin and delivered the medication to each wing. When she delivered the medication from the bin to the [NAME] Wing (GW), she was unable to locate the RN so she told LPN-A that she was placing the medication delivery on the table in the report room. LPN-A responded verbally that she would take care of it. The medication was left on the table for an unknown length of time, unattended and not locked. Later that day the after shift report LPN-B went into the medication room and opened the cupboard that holds the narcotic medication emergency kit (E-kit). There were 2 kits in the cupboard,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review the facility failed to ensure 1 of 1 package of routine and controlled narcotic medication, delivered by a package delivery service, was immediately secured into staff custody upon arrival, and when transported by staff and delivered to another unit. Findings include: Interview on 7/10/24 at 1:42 p.m., with LPN-C identified on 6/15/24, she realized medication had not been delivered to the wing, so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door unattended. The bin was secured with 2 plastic zip ties. She delivered the medications to the appropriate wings. She told licensed practical nurse (LPN)-A that she placed the newly delivered medication on the table in the unlocked report room. LPN-A responded verbally she would take care of it. LPN-C. LPN-C failed to notify the DON or administrator of the lack of the delivery driver to drop off medication in a hand off and not leave the medication unattended where potential diversion could occur from passers-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 · E2023-10-04 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 side rails were assessed to determine appropriateness and safety of use for 4 of 4 residents (R9, R16, R30 and R31) who was observed to have a side rails affixed to their beds. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and required extensive assistance with bed mobility and transfers. R9's diagnoses included traumatic brain dysfunction (head injury causing damage to the brain by external force or mechanism), hemiplegia (condition that causes paralysis or weakness on one side of the body) and contracture of muscle, multiple sites. R9's care plan dated 7/7/23, included that R9 utilized bilateral assist device bars on bed to assist with bed mobility. Additionally, the care plan included that R9 needs assistance of two staff to boost up in bed. On 10/2/23 at 2:25 p.m., Observed R9's bed had 1/2 side rails affixed to the head of bed on both sides of bed. R9's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 notify the county (designated State Mental Health Authority) for 1 of 1 resident (R49) with new onset of mental illness. Findings include: R49's 4/5/23, Initial Pre-admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II PASARR to be completed. R49's 4/12/23, admission Minimum Data Set (MDS) assessment identified R49 was admitted on [DATE]. R49's cognition was intact with diagnoses of anxiety, depression and Post Traumatic Stress Disorder. R49 had disorganized thinking, felt tired and having little energy, feeling bad about himself or feeling like he let his family down, and had trouble concentrating during the 14-day assessment period. Additionally, R49's 7/13/23, quarterly MDS identified R49 continued to have disorganized thinking, had little interest or pleasure in doing things, feeling down, depressed or hopeless, thought he would be better off dead, or of hurting himself in someway…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-04 · 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 ensure nursing assistant (NA) staff correctly transferred 1 of 1 resident (R47) resident with use of 2 staff during a mechanical sit to stand lift transfer to ensure his safety. Findings included: On 10/2/23 at 1:52 p.m., R47 stated that he needs two staff to assist him with transferring, with the mechanical lift, when he gets in and out of recliner. On 10/2/23 at 2:31 p.m., nursing assistant (NA)-A brought a mechanical lift into R47's room and assisted R47 with transferring from recliner to wheelchair with one staff. R47's annual Minimum Data Set (MDS) dated [DATE], identified R47 was cognitively intact and required extensive assistance from two staff for transfers. R47's diagnoses included Parkinson's disease (condition that affects the brain and causes problems with movement, balance, and coordination), myasthenia gravis (neuromuscular disorder that leads to weakness of skeletal muscles) and dependence on other enabling machines 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BUCHANAN, SCOTT | Individual | W-2 MANAGING EMPLOYEE | since 01/19/2021 |
| CURTIS, NANCY | Individual | W-2 MANAGING EMPLOYEE | since 12/24/2018 |
| HUGHES, DOUGLAS | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 07/05/2016 |
| STEGENGA, ANNE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 05/03/1993 |
CMS files one row per role, so the 6 rows in the source record cover these 4 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.
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 245631. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-10, 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.