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Oaklawn Health Care, LLC

201 Oaklawn Avenue, Mankato, MN 56001 · For profit - Corporation · 60 certified beds · (507) 388-2913 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Oct 20231 immediate-jeopardy citation$41,357 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $41,357 in federal fines (most recent 2023-10-27)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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

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

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

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1230 E Main St 2nd Floor · (507) 389-8522 · Call to confirm hours
Pharmacy
1175 Madison Ave · (800) 746-7287 · Call to confirm hours
Grocery
505 N Riverfront Dr · (507) 779-7335 · Call to confirm hours
Park
900 E Main St. · (507) 387-8649 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 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 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.3%18.2%15.4%worse
Long-stay residents who lose too much weight6.0%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.9%2.6%2.0%worse
Long-stay residents with depressive symptoms0.0%4.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%4.0%3.3%typical
Long-stay residents whose ability to walk worsened10.7%20.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.7%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine95.7%96.1%95.3%typical
Long-stay residents with pressure ulcers6.9%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control27.6%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table28.1%17.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine95.5%82.7%79.4%better
Short-stay residents rehospitalized after admission15.6%23.5%22.6%better
Short-stay residents with an outpatient ER visit21.9%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.021.611.67worse
Long-stay outpatient ER visits per 1,000 resident days1.681.901.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

65.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.4%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
66.0%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 66.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.4%CMS range 55.8–73.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.2–12.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified88.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.7–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.51
RN hours/ resident / day
0.40
LPN hours/ resident / day
1.89
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
1.18
RN hoursweekends
66.3%
Total nursing turnover
52.4%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 52.9 residents a day — about 88% occupied, or roughly 7 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.51 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 3.97 on weekdays — 15% thinner on weekends. RN hours go from 1.64 to 1.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-06-10)
7
at the previous standard inspection (2025-04-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2023-10-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines for Med Care lift that expired, and ensuring correct sling/harness sizes for 7 of 7 residents (R4, R5, R6, R7, R8, R9, R10) who utilized this mechanical lifts. This resulted in an immediate jeopardy (IJ) for R1 who fell from the Med Care sit to stand lift resulting a fractured right femur (thigh bone) on 10/9/23. This had the likelihood for serious harm, impairment or death for R4, R5, R6, R7, R8, R9 and R10 who continued to use this Med Care sit to stand lift. In addition, the facility failed to ensure a preventive lift maintenance program was followed and staff had knowledge of using the correct size harness/sling size for their mechanical lifts. The IJ began on 10/9/23 at 9:05 p.m., when facility staff did not use two staff to transfer R1 in accordance with the care plan and follow manufacturer guidelines for Med Care lift that had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the consultant pharmacist identified and reported a medication irregularity during the required monthly drug regimen review for 1 of 1 residents (R1), when an unauthorized Haloperidol order remained active despite the resident's diagnoses of epilepsy and Parkinsonism. This failure resulted in the medication remaining on the resident's medication regimen from March through June 2026 without identification during the required monthly pharmacist reviews.R1's face sheet dated 6/17/26, identified diagnoses of localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures not intractable without status epilepticus (abnormal electrical activity begins in a specific area of the brain rather than the entire brain, hallucinations, and parkinsonism (condition that affects movement). R1's Medication Administration Record (MAR) dated 3/2026, identified an order for Haloperidol Lactate oral concentration (Haldol) 2 milligrams (mg)/milliliter (mL). Give 1.5 mL by mouth at bedtime…

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

    Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 1 residents (R1) was free from a significant medication error when Haloperidol was entered into the facility's integrated electronic medication ordering system and administered to R1 from 3/13/26 through 6/9/26 without a valid and verified physician order.Findings include:The Nursing Home Incident Report (NHIR) submitted to the State Agency (SA) identified Haloperidol order intended for another resident was inadvertently entered into R1's chart. Medication was administered until review following seizure activity and discontinued upon discovery.R1's face sheet dated 6/17/26, identified diagnoses of localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures not intractable without status epilepticus (abnormal electrical activity begins in a specific area of the brain rather than the entire brain, hallucinations, and parkinsonism (condition that affects movement).R1's quarterly Minimum…

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

    Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 observation, interview, and record review the facility failed to remove discontinued medications from the active medication storage for 2 of 2 residents (R3, R4) creating the potential for inadvertent medication administration. Findings include: R3During an observation and interview on 6/17/26 at 12:36 p.m., Registered nurse (RN)-A opened the medication cart and went to R3's medication section. RN-A observed R3's Lidocaine patches and Quetiapine Fumarate (Seroquel) remained in the medication cart. RN-A reviewed R3's current medication orders and stated there was not a current order for Seroquel or Lidocaine patches. RN-A removed the medications from the medication cart and stated medications should be removed from the medication cart right away after the order was discontinued to avoid medication errors. RN-A stated it was basic nursing knowledge to remove discontinued medications from the medication cart. R3's face sheet dated 6/17/26, identified diagnoses of fracture of one right rib, other chronic pain, agoraphobia with panic disorder, and generalized anxiety…

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

    Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · F2026-06-10 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a safe, sanitary and comfortable environment for 1 of 1 residents (R2) whose room was unkept and had resident care items placed on the floor. In addition, the facility failed to perform daily cleaning in the kitchen which had the potential to affect 54/56 residents who received food from the kitchen. Findings include:R2R2's face sheet received on 6/10/26, included diagnoses of diabetes, dementia, and chronic gastritis (inflammation of stomach lining).R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R2 was able to eat independently and required substantial assistance or was dependent on staff for activities of daily living (ADLs). R2 did not walk. R2's physician orders dated 9/24/25, indicated to apply foot to calf wraps (black) at bedtime. Orders dated 3/23/26, indicated Ready Wraps firm and snug around foot, ankle, and calf in the morning.…

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

    Environmental Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-06-10 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 nutrient and/or calorie substantive snacks were offered after the evening meal and before bedtime, for 2 of 2 residents (R2, R42) when there had been more than a 14-hour lapse between the dinner meal and breakfast the following day. This had the potential to affect 54 of 56 residents who ate meals at the facility. Findings include:R2R2's face sheet received on 6/10/26, included diagnoses of diabetes, dementia, and chronic gastritis. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R2 was able to eat independently but required substantial assistance or was dependent on staff for activities of daily living (ADLs). R2 did not walk. R2's physician orders dated 1/20/26, included Con/CHO (controlled carbohydrate) 2-gram sodium diet, regular.R2's care plan dated 3/11/26, indicated potential for alteration in nutrition related to diagnoses. During…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure appropriate follow-up of urine culture and sensitivity results and failed to ensure antibiotic therapy was reviewed for effectiveness for 1 of 1 resident (R32) reviewed for antibiotic use. In addition, the facility failed to ensure a nutritious snack was offered for the management of low blood sugar and failed to inform the dietician of concerns with blood sugar levels for 1 of 1 resident (R50) reviewed for food.Findings include: Antibiotic Use R32's significant change in status [NAME] Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, utilized a wheelchair, required supervision or touching assistance with toileting hygiene and personal hygiene, diagnoses included bladder cancer, hydronephrosis (urine doesn't fully empty from the body), and hematuria (blood in urine). R32's care plan dated 5/5/26, indicated alteration in elimination d/t (due to) weakness and assist with 2 staff and transfers, bladder cancer 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to assess and implement interventions to maintain and/or prevent loss of range of motion (ROM) for 1 of 1 resident (R21) reviewed for ROM.Findings include: R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, utilized a wheelchair, independent with eating, setup or clean-up assistance with oral hygiene, dependent with toileting hygiene, sit to lying, chair to bed transfer, toilet transfer, lower body dressing, substantial/maximal assistance with shower/bathe self, roll left and right, upper body dressing, and partial moderate assistance with personal hygiene; limitation range of motion on both sides of lower extremity and no impairment on upper extremity; diagnoses included non-Alzheimer's dementia, depression, Parkinsonism and not receiving a restorative nursing program.R21's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, no rejection…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-03-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a comprehensive care plan for diabetic management that included goals and individualized interventions was developed or 1 of 3 residents (R2) reviewed for care plans.Findings include:R2's face sheet dated 2/27/26, identified diagnoses of type 2 diabetes with hyperglycemia.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive deficits, was on a therapeutic diet, and took hypoglycemic medications (used to lower blood glucose).R2's medication administration record (MAR) for January 2026, identified an order from 9/12/24, that was for a FreeStyle Libre 2 Sensor continuous blood glucose monitoring system sensor to be applied every 14 days.R2's care plan current at the time of survey included R2's diagnosis of diabetes as a related factor of the focus which included (but not limited to) falls, vulnerable adult, nutrition, skin integrity, however, R2's care plan did not include diabetic focus that identified…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff implemented proper peri care techniques, including use of Enhanced Barrier Precautions (EBP), appropriate glove changes, and hand hygiene, to prevent or mitigate the risk of urinary tract infections for 2 of 2 residents (R2, R4) reviewed for peri care.Findings include:Findings include:R2's face sheet dated 2/27/26, identified diagnoses of cystitis without hematuria (bladder infection commonly caused by Escherichia coli (commonly entered into the urinary tract through contamination of feces), neuromuscular dysfunction of the bladder (nerve damage impairs bladder control), and personal history of urinary tract infections (UTI).R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no cognitive deficits, dependent on staff for toileting needs, resident had a urinary catheter with occasional bowel incontinence.R2's care plan dated 4/19/24, identified Enhanced Barrier Precautions (EBP) related to indwelling foley…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 professional standards of practice were followed during administration of eye drops for 3 of 3 residents (R12, R15, R106) observed for medication administration. Findings include: R12's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R12 was cognitively intact, no rejection of care, required, maximal assistance with personal hygiene, and diagnoses included progressive neurological conditions, hemiplegia or hemiparesis (weakness or partial paralysis on one side of the body), and multiple sclerosis (central nervous system autoimmune condition. Damage to myelin causes symptoms like muscle weakness and vision changes) . R12's care plan dated on 4/1/25, did not indicate any care needs related to her eyes. R12's medication review report printed 4/15/25, indicated Artificial Tears Ophthalmic Solution 1-0.3% (Propylene Glycol-Glycerin) instill one drop in left eye three times a day for dry eye and instill two drop in right…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2025-04-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 shaving for 1 of 1 resident (R45) who was dependent on staff for assistance with grooming and personal hygiene. Findings include: R45's facesheet dated printed 4/16/25, indicated diagnoses included muscle weakness, pain, high blood pressure, and heart failure. R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 was cognitively intact, used a wheelchair, independent with eating, dependent for bathing and personal hygiene. R45's care plan printed 4/16/25, indicated R45 required staff assist of one for toileting, oral care, bathing, and personal hygiene. During interview and observation on 4/14/25 at 1:53 p.m., R45 had 6 visible chin hairs measuring varying lengths up to ½ inch long. R45 had a razor on her bedside table. R45 stated she did not like having chin hairs and wanted staff to shave her chin but thought staff were too busy. During interview and observation on 4/15/25 at 8:39 a.m., R45 was seated in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a safe smoking area, extinguishing of cigarettes in designated container, and monitoring of designated smoking area for 2 of 2 residents (R20 and R18) reviewed for smoking. Findings include: R18's facesheet printed 4/16/25, indicated diagnoses of spina bifida, nicotine dependence, and obesity. R18's admission minimum data set (MDS) assessment dated [DATE], indicated intact cognition, use of wheelchair, dependent for bathing, and setup assistance for personal hygiene. R18's care plan printed 4/16/25, indicated resident currently smoked and would smoke safely in designated areas per facility policy. R20's face sheet printed 4/16/25, indicated diagnoses of type two diabetes mellitus and malnutrition. R20's annual MDS dated [DATE], indicated intact cognition, use of wheelchair, substantial assistance with toileting hygiene, and partial assistance with personal hygiene. R20's care plan printed 4/16/25, indicated resident currently…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the culinary services director (CSD)-B was certified to oversee nutrition and food services. This had potential to affect all 45 residents who received meals from the kitchen. Findings include: During the initial kitchen tour on 4/14/25 at 9:40 a.m., CSD-B who had been employed in this role for two years, stated she was not a certified dietary manager (CDM). CSD-B stated she had been enrolled in the course at one time but was not able to complete it. During an interview on 4/15/25 at 11:25 a.m., CSD-B stated the administrator had registered her for the CDM course that morning (4/15/25), and she was now enrolled to take the course. During an interview on 4/15/25 at 2:39 p.m., registered dietician (RD)-C stated she worked part-time at the facility, usually one or two days a week, and communicated frequently with CSD-B via email or phone. RD-C acknowledged CSD-B was new to resident clinical issues, such as monitoring resident weights, but did well on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure 2 of 2 refrigerator/freezers designated for resident food brought into the facility, were monitored to ensure food items were properly stored, labeled, and dated to reduce the risk of contamination and/or foodborne illness. This had the potential to affect any resident who utilized the refrigerator/freezers. In addition, the facility failed to ensure a culinary services cook (CSC)-A wore covering over beard to prevent hair from contaminating food, surfaces and utensils. This had the potential to affect all 45 residents who ate food prepared in the kitchen. Findings include: North Wing Resident Refrigerator: During an observation on 4/14/25 at 2:54 p.m., the resident refrigerator on the North wing was a side-by-side refrigerator/freezer. On the outside of the refrigerator was a sign that indicated: All items placed in this refrigerator must be in a sealed container with name and date. Perishable items are kept for 3 days. A sign on the freezer indicated: All items placed in refrigerator and freezer…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was donned (put on) and doffed (removed) appropriately for 1 of 1 resident (R206) who had been in transmission-based precautions (TBP) due to testing positive for Covid-19. Findings include: R206's facesheet printed on 4/16/25, indicated R206 was admitted on [DATE], with a diagnosis of Covid-19. R206's physician orders dated 4/11/25, indicated: due to Covid positive status, R206 was to remain on enhanced respiratory precautions and strict isolation during the contagious stage. R206's care plan dated 4/11/25, indicated R206 was on enhanced respiratory precautions related to Covid-19 infection. Staff would follow enhanced respiratory precautions. During an observation on 4/14/25 at 6:25 p.m., observed nursing assistant (NA)-A don PPE to go into R206's room. NA-A donned all appropriate PPE except eye protection. At 6:28 p.m., NA-A exited the room with all PPE having been removed prior to exiting…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the pneumococcal (PCV20) vaccine was offered or administered as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R157) reviewed for immunizations. Findings include: R157's facesheet printed on 4/16/25, indicated and admission date of 4/7/25, and diagnoses of heart failure, muscle weakness, fatigue, and obesity. R157's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and no rejection of care. R157's physician's orders printed on 4/16/25, indicated a past history of pneumonia, unspecified organism. R157's care plan dated 4/7/25, indicated a self care deficit related to weakness and visual impairment and need for assistance with dressing, personal hygiene, and bathing. During record review, there was no documentation in R157's EMR (electronic medical record) for the PCV 20 vaccine or evidence the vaccine had been offered or refused. During interview on 4/16/25 at 2:56 p.m., director of nursing…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-06 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to coordinate an appointment with a dental provider for 1 of 1 resident (R8) who requested a dental appointment for dentures. Findings include: R8's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R8 had moderately impaired cognition, required partial/moderate assistance with oral hygiene, no natural teeth or tooth fragment(s)and diagnoses included arthritis, non-Alzheimer's dementia, anxiety disorder, depression, and macular degeneration (eye disease that affects vision). R8's care plan dated 8/8/23, indicated self-care deficit related to wedge compression fracture, DM2 (diabetes type two), asthma and HTN (hypertension) AEB (as evidenced by) assistance with ADL (activities of daily living) and interventions included assist with personal hygiene with assist of one. R8's oral/dental evaluation dated 12/28/23, licensed practical nurse (LPN)-A indicated R8 had mouth or facial pain that does not impair…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 record review the facility failed to ensure timely reporting to the State Agency (SA) was completed when 1 of 1 resident (R1) fell from a mechanical lift as a result of NA not following the care plan which resulted in a right femur fracture. Findings include: Facility reported incident (FRI) submitted to the SA on 10/10/23, at 4:35 p.m. identified R1 had a fall from the mechanical lift on 10/9/23, at 9:05 p.m. that resulted in R1 fracturing his right femur, when NA-C transferred R1 via sit to stand to toilet. R1 became weak and fell from lift. NA-C notified nurse immediately. Nurse came immediately assessed that R1 was in pain, called 911 for transfer to emergency room (ER). Provider and family made aware. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had diagnoses of monoplegia (weakness) of the right side, unspecified dementia, cerebral infarction (stroke), anxiety, and depression. The cognition section was not completed for this assessment, however, MDS 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure proper catheter cleaning and storage was provided to prevent possible urinary tract infections (UTIs) for 4 of 6 residents (R1, R3, R5 and R15) observed for catheter use. Findings included: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses of neurogenic bladder (define what this is), cancer, urinary tract infections (UTI) in the last 30 days, diabetes, and stroke. R1 had an indwelling urinary catheter and was always continent of bowel. R1's bowel and bladder care plan 7/7/22 indicated R1 had altered elimination related to impaired mobility and function due to hemiplegia and hemiparesis following right sided stroke, history of UTIs, sepsis, and bladder cancer scope done on 4/3/23 that showed friable tissue over posterior bladder wall. Additionally, R1 had history of TURBT (trans urethral resection of bladder tumor) on 5/16/23 with significant hematuria (blood in urine) and indwelling urinary catheter…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-09 · tag F0585 — failed to handle grievances — widespread
    Honor 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

    Based on observation, interview and document review, the facility failed to establish a grievance policy to ensure residents could voice grievances anonymously and without fear of discrimination or reprisal. In addition, the facility failed to post in prominent locations throughout the facility the right to file grievances orally or in writing; the right to file grievances anonymously; and the name and contact information of the grievance official with whom a grievance could be filed. This deficient practice had the potential to affect all 50 residents and visitors in the facility. Findings include: During an observation on 8/9/23 at 10:00 a.m., the facility lacked a posting of the grievance process as well as no grievance forms were available in prominent locations in the facility. A Minnesota [NAME] of Rights poster was observed in the main hallway of the facility and listed facility contacts of an administrator, director of nursing (DON) and two social services representatives. All four contacts listed on the poster were no longer employed at the facility. Grievance official was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$41,357 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $32,183 — penalty dated 2023-10-27
  • $4,587 — penalty dated 2023-08-28
  • $4,587 — penalty dated 2023-08-21
  • Medicare payment denial — starting 2023-11-28 for 20 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 MONARCH HEALTHCARE MANAGEMENT — 45 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 44 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Hillcrest Health Care, LLCMankato, MN 1 of 5Maplewood Rehabilitation CenterMaplewood, MN 1 of 5The Emeralds At Fairbault LLCFaribault, MN 1 of 5The Emeralds At Grand Rapids LLCGrand Rapids, MN 1 of 5The Emeralds At St Paul LLCSaint Paul, MN 1 of 5The Estates At Excelsior LLCExcelsior, MN 1 of 5The Estates At Lynnhurst LLCSaint Paul, MN 1 of 5The Villas At BrookviewGolden Valley, MN 1 of 5The Villas At New BrightonNew Brighton, MN 1 of 5The Villas At Osseo LLCOsseo, MN 1 of 5The Villas At RobbinsdaleRobbinsdale, MN 1 of 5The Villas At The CedarsSaint Louis Park, MN 1 of 5The Waterview Pines LLCVirginia, MN 1 of 5The Waterview Shores LLCTwo Harbors, MN 1 of 5The Waterview Woods LLCEveleth, MN 1 of 5Villas At Bryn Mawr LLCMinneapolis, MN 2 of 5Bayside Manor LLCGaylord, MN 2 of 5Parmly On The Lake LLCChisago City, MN 2 of 5The Estates At Chateau LLCMinneapolis, MN 2 of 5The Estates At Fridley LLCFridley, MN 2 of 5The Estates At Roseville LLCRoseville, MN 2 of 5The Estates At Rush City LLCRush City, MN 2 of 5The Estates At Twin Rivers LLCAnoka, MN 2 of 5The Gardens At Foley LLCFoley, MN 2 of 5The Gardens At Winsted LLCWinsted, MN 2 of 5The North Shore Estates LLCDuluth, MN 2 of 5The Villas At St Louis ParkSaint Louis Park, MN 2 of 5The Villas At St PaulSaint Paul, MN 2 of 5The Villas At The ParkSaint Louis Park, MN 3 of 5Bethany On The Lake LLCAlexandria, MN 3 of 5Laurels Peak Health Care, LLCMankato, MN 3 of 5Meeker Manor Rehablitation Center, LLCLitchfield, MN 3 of 5River Valley Health And Rehabilitation Center LLCRedwood Falls, MN 3 of 5The Estates At Bloomington LLCBloomington, MN 3 of 5The Estates At St Louis Park LLCSaint Louis Park, MN 3 of 5The Villas At RichfieldRichfield, MN 3 of 5The Villas At RosevilleRoseville, MN 4 of 5Lakeshore Rehabilitation Center LLCWaseca, MN 4 of 5Mala Strana Health Care, LLCNew Prague, MN 4 of 5Sleepy Eye Rehabilitati CenterSleepy Eye, MN

Showing 40 of 44; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
HML LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 07/01/2015
SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST23%since 07/01/2015
YAZOMA HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST23%since 07/01/2015
AREM, JEFFREYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 07/01/2015
JAFFA, NOAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 07/01/2015
STERN, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER15%since 07/01/2015
HALPERT, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE23%since 07/01/2015
LEGUM, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER23%since 07/01/2015
MUENCZ, JEFFREYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER13%since 07/01/2015
MONARCH HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$7.5M
Net patient revenuemost recent cost report
+0.5%
Operating marginrevenue minus expenses
$1.0M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 13%Other / private 46%

This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$408per resident / day
operating cost
$12,395per month
≈ monthly operating cost
$410per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245517. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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.

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