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Harmony Gardens

1438 County Road C East, Maplewood, MN 55109 · Non profit - Corporation · 64 certified beds · (651) 488-6658 Medicare & Medicaid certified

Call the home — (651) 488-6658 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Mar 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1560 Beam Ave · (651) 340-1445 · Call to confirm hours
Pharmacy
1580 Beam Ave · (651) 255-8480 · Call to confirm hours
Grocery
2501 White Bear Ave N · (651) 747-3500 · Call to confirm hours
Park
2561 Barclay St · Typically dawn to dusk
Place of worship
2555 Hazelwood St · (651) 776-2361

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 4 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 improved from 4 to 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.

Overall rating5★
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 increased16.8%18.2%15.4%typical
Long-stay residents who lose too much weight2.1%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.5%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.0%2.6%2.0%worse
Long-stay residents with depressive symptoms7.5%4.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.7%4.0%3.3%typical
Long-stay residents whose ability to walk worsened26.0%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication7.1%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.6%96.1%95.3%typical
Long-stay residents with pressure ulcers2.7%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control17.1%24.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.8%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine78.1%82.7%79.4%typical
Short-stay residents rehospitalized after admission29.3%23.5%22.6%worse
Short-stay residents with an outpatient ER visit11.4%14.8%12.0%typical

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.

68.9% 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 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.9%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 60.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 69 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.9%CMS range 60.5–75.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.1–16.510.7%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 discharge60.9%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 discharge60.9%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 discharge49.3%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 identified97.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge88.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 hospitalization6.0%CMS range 3.2–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.731.02Oct 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

1.40
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.46
Aide hours/ resident / day
4.64
Total nurse hours/ resident / day
1.06
RN hoursweekends
24.7%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 59.6 residents a day — about 93% occupied, or roughly 4 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 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.40 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 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 4.21 hrs/resident/day on weekends vs 4.82 on weekdays — 13% thinner on weekends. RN hours go from 1.54 to 1.06 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% 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

4
deficiencies at the latest standard inspection (2026-03-26)
10
at the previous standard inspection (2025-01-09)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2024-09-19 · 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 care planned interventions were followed during transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to use a transfer belt. This resulted in actual harm for R1 who fell during a staff assisted transfer and sustained a subarachnoid hemorrhage. The deficient practice was corrected prior to the start of the survey therefore, was issued at past noncompliance. Findings include: R1's Resident Face Sheet indicated R 1 was re-admitted to the facility on [DATE]. The face sheet identified diagnosis that included vascular dementia, cerebral infarction with left sided weakness, anemia and heart failure. R1's admission Minimum Data Set, dated [DATE], identified intact cognition and indicated he required partial to moderate assistance for transfers. R1's care plan dated 9/3/24, indicated impaired self ability with transfers and ambulation. The care plan directed staff to provide contact guard assistance with transfers.…

    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 · Past Non-Compliance
  • Potential for harm · F2026-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated, and not expired. This had the potential to affect all 61 residents who received food from the facility kitchen. Findings include:On 3/25/26 at 10:40 a.m., director of food and nutrition (DFN) provided a tour of the facility kitchen. In the walk-in refrigerator there was a container of beets labeled with an opened date of 2/23. Multiple white patches of a substance were observed on the top surface of the beets. DFN confirmed and stated the substance was mold. DNF further stated the beets had been opened longer than seven days and should have been discarded. In addition, a container of potato salad was observed in the same refrigerator, labeled with an opened date of 3/10. DNF confirmed and stated the potato salad was expired and should have been discarded. In a standalone refrigerator, an individual sized prepared salad, a half-full container of fresh strawberries and a quarter-full container of fresh blueberries were observed with no label or…

    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 · D2026-03-26 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure pillows were not used in a manner to restrain residents while in bed for 1 of 1 resident (R44) reviewed for restraints.Findings include:R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had severe cognitive impairment, required substantial/maximal assistance for bed mobility, and was dependent for transfers. R44's MDS further indicated R44 did not experience any falls since admission, was receiving hospice care and did not use any restraints. R44's diagnoses included generalized muscle weakness, adjustment disorder with mixed anxiety and depressed mood, and chronic obstructive pulmonary disease (COPD, chronic lung disease). R44's care plan dated 3/10/26, indicated R44 was at risk for falls and used body pillows to define the edge of the bed. R44's nursing care sheet printed 3/9/26, indicated R44 required two-person assistance using a mechanical lift for transfers and one person assist every 2-3 hours for…

    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 · D2026-03-26 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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 a subset (i.e., discharge) Minimum Data Set (MDS) was completed and transmitted to the Centers for Medicare and Medicaid (CMS) database in a timely manner for 1 of 1 resident (R30) reviewed for MDS accuracy. Findings include: The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual), dated 10/2025, identified all applicable MDS along with their completion and transmission dates were required. This included, Discharge Assessment - return not anticipated, listed with a transmission date of, MDS Completion Date + 14 calendar days. R30's Census List, printed 3/26/26, identified R30's most recent admission to the facility as 11/4/25. R30 remained in the facility in the same room until 12/5/25. The census identified R30's status on 12/5/25 as Discharge-Return Not Anticipated. R30's progress note dated 12/5/25 at 1:22 p.m., indicated R30 discharged from community at1:23 p.m.Review of R30's MDS 3.0 resident assessments list printed on 3/25/26, indicated an admission and 5-day assessment…

    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 before2026-03-26 · 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 document review the facility failed to assess residents' ability to independently empty and report urine output for 1 of 1 resident (R50) reviewed who had a urinary catheter. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Parkinson's disease, urine retention, and overactive bladder. It further indicated R50 had an indwelling catheter and was independent with toileting. R50's physician's order dated 2/19/21, indicated catheter care: catheter output three times a day. R50's care plan reviewed/revised 2/26/26, indicated R50 had a chronic supra pubic catheter (long term use urinary catheter via abdominal incision) changed monthly by urologist due to inability to manage with straight catheter, urinary retention enlarged, prostrate and history of urinary tract infections (UTI). Interventions included catheter cares, monitor for UTI, monitor and report any concerns, monitor urine output every shift and notify…

    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 · E2025-04-04 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately assess physical restraints (manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for 4 of 4 residents (R1, R2, R3 and R4) reviewed who use bedrails. Findings include: Long-Term Care Facility Resident Assessment User Manual Version 1.18.11, dated October 2023, viewed 8/26/24 indicated a physical restraint or method physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored. Any manual method or…

    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 · E2025-04-04 · tag F0700 — pattern
    Try 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 record review the facility failed to attempt alternative devices before using bedrails on residents beds, assess the residents for risk of entrapment, review risks and benefits for bed rail use, ensure bed dimensions were appropriate for 4 of 4 residents (R1, R2, R3 and R4) review for bed rails. Findings include: Food and Drug Administration (FDA) guidelines (Recommendations for Health Care Providers about Bed Rails) 2018 indicated health care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions, health care providers are to avoid the routine use of adult…

    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 · D2025-04-04 · 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 observation, interview, and record review the facility failed to immediately report allegations of abuse and injury of unknow origin to the State Agency (SA) no later than two hours after the allegation is made for 1 of 1 resident (R1) reviewed. R1's family filed a facility grievance that indicated staff was aggressive with R1 and a facility nurse found bruising that were similar to finger marks on R1's upper arm where a cause was not identified. Neither event was reported. Findings include: R1's admission Minimum Data Set, dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 9 indicting R1 was moderately cognitively impaired. R1 required maximum assistance with toileting, showering, dressing, personal hygiene and rolling in bed. R1 was dependent on staff for bed to chair transferring. R1 was always incontinent of bowel and bladder. R1's pertinent diagnoses were hemiplegia and hemiparesis following cerebral infarction affecting the nondominant side (muscle weakness 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide evidence that a thorough investigation was completed on allegations of an injury of unknown origin for 1 of 4 residents (R1) reviewed. Staff found bruising resembling finger markings on R1's upper arm. R1's family had filed a grievance report regarding aggressive care one day prior to the bruising findings. Findings include: Facility record grievance review dated 1/1/25 - 4/3/25 did not reveal any documented grievance or investigation regarding R1's bruising an injury of unknown origin. R1's admission Minimum Data Set, dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 9 indicting R1 was moderately cognitively impaired. R1 required maximum assistance with toileting, showering, dressing, personal hygiene and rolling in bed. R1 was dependent on staff for bed to chair transferring. R1 was always incontinent of bowel and bladder. R1's pertinent diagnoses were hemiplegia and hemiparesis following cerebral…

    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 · F2025-01-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to follow transmission based precautions (TBP) based on signage located outside resident's doors for R29, R45, R17, R14. This had the potential to affect all residents. Additionally, the facility failed to ensure hand hygiene was completed during 3 of 6 residents (R14, R55, R47) observed for medication administration. Findings include: According to the Centers for Disease Control (CDC) website, transmission based precautions are the second tier of basic infection control and are to be used in addition to standard precautions (standard precautions is based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents) for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. The CDC website…

    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 · D2025-01-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed ensure timely care was provided in a manner to maintain and enhance quality of life for 1 of 2 residents (R64) reviewed for call lights. Findings include: R64's admission Minimum Data Set (MDS) 11/30/24 indicated R64 had mild cognitive impairment and diagnoses of heart failure and sepsis (systemic infection). R64 required extensive assist of one person for bed mobility and transfers. R64's care plan dated 11/29/24, indicated R64 had impaired self-performance with toileting due to weakness and sepsis. R64 was incontinent of bowel and continent of bladder. Interventions included toilet upon rising, after meals and before going to bed as needed. R64 required max assistance from staff for toileting. R64's nursing assistant (NA) care sheet obtained 1/6/25, indicated R64 required toileting via Hoyer lift or bedpan upon rising, after meals and before going to bed as needed. R64's call light report for 1/7/25, indicated R64's call light was placed at 1:52 p.m. and was closed at 1:56 p.m. An observation on 1/7/25 at 2:06…

    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
Show the remaining 12 citations
  • Potential for harm · D2025-01-09 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were comprehensively assessed safe for self-administration of medication for 1 of 1 resident (R36) reviewed and observed for self-administration of medications. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 was cognitively intact, was taking high-risk drug class medications, and had diagnoses of type 2 diabetes, neuropathy (damage or disease affecting nerves and may impair sensation and movement), dysphagia (difficulty swallowing), weakness, respiratory disease, and congestive heart failure. R36's provider orders dated 3/27/23, indicated, acetaminophen [OTC] tablet; 500 mg; amt: 1000 mg; oral Three Times A Day 08:00, 14:00 [2:00 p.m.], 20:00 [8:00 p.m.]. R36's provider orders lacked evidence for SAM. R36's SAM observation form dated 10/4/24, indicated whether the resident desired to self-administer medications with a response selected as follows, No-If no, there is no need to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure ambulation program was completed daily for 1 of 1 residents (R62) who was reviewed for ambulation. Findings included: R62's annual Minimum Data Set (MDS) dated [DATE], indicated R62 was cognitively intact, required supervision or touching assistance for walking 150 feet in a corridor or similar space, and did not exhibit rejection of care behaviors. R62's diagnoses included type 2 diabetes, major depressive disorder, osteoarthritis, and muscle weakness. R62's care plan last reviewed 11/6/24, indicated, AMBULATION: Resident requires assistance with ambulation due to generalized weakness. Resident will maintain the ability to ambulate. See ambulation program for details. R62's care plan further indicated, Resident has participated well in therapies and has desire to participate in a restorative ambulation program. Resident agrees to participate in this program. Resident will participate in restorative walking program at least 5…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure care planned interventions were implemented for 1 of 2 residents (R64) reviewed for pressure injury. Findings include: R64's admission Minimum Data Set (MDS) 11/30/24 indicated R64 had mild cognitive impairment and diagnoses of heart failure and sepsis (systemic infection). R64 required extensive assist of one person for bed mobility and transfers. Furthermore, R64 was at risk for pressure injury. R64's comprehensive skin assessment dated [DATE], indicated R64 was high risk for pressure injury. R64's pressure injury Care Area Assessment (CAA) dated 11/30/24, indicated R64 was at risk for pressure injury due to immobility, poor nutrition, and cognitive loss. R64's care plan dated 11/29/24, indicated R64 was at risk for skin alterations related to sepsis, heart failure, and recent assistance of daily living (ADL) decline. Interventions included elevate heels off the bed with pillows and to position body with supports/pillows to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · 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 ensure a hand splint was used for 1 of 1 resident (R30) reviewed for range of motion (ROM). Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE] indicated R30 had mild cognitive impairment, required substantial/maximal assistance with most activities of daily living (ADLs), and did not exhibit rejection of care behavior. The MDS indicated R30 did not perform any restorative nursing programs to include splint brace assistance. R30's diagnoses included vascular dementia, muscle weakness and neuralgia and neuritis (inflammation and pain along a nerve path). R30's care plan last reviewed 1/6/25, indicated, Resident to ear yellow splint for 2-3 hours daily, to ensure optimal joint protection and for progression with function. R30's Resident Profile printed 1/10/25, indicated, Resident will wear splint for 2-3 hours .to L wrist .daily as recommended by OT [occupational therapy]. R30's OT note dated 1/3/24, indicated, R30 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · 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 comprehensively assess and implement interventions necessary to maintain continence for 1 of 1 residents (R27) reviewed for bowel and bladder. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and diagnoses of cerebral infarction (stroke) with left sided hemiplegia (inability to move one side of the body) and edema. Furthermore, R27's MDS indicated R27 had no rejection of cares, had occasional incontinence of bowel and bladder and no toileting program. R27's comprehensive bowel and bladder assessment dated [DATE], indicated R27 was fully continent of bowel and bladder. Furthermore, the comprehensive assessment lacked review of R27's cognitive awareness, diuretic use, observation of bladder/bowel function, potential voiding difficulties, or toileting patterns. R27's urinary incontinence care area assessment (CAA) dated 3/25/24, indicated R27's was frequently incontinent of bladder 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 date of correction
  • Potential for harm · D2025-01-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure weekly weights were completed for 1 of 1 resident (R32) who was reviewed for nutrition. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had severe cognitive impairment, required substantial/maximal assistance with eating, and did not exhibit rejection of care behavior. R32's diagnoses included hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) following cerebral infarction (stroke) affecting left non-dominant side, vascular dementia, type 2 diabetes mellitus, and dysphagia (difficulty swallowing). R32's care plan (CP) last reviewed 11/6/24, indicated, Resident requires regular texture without restrictions related to weight loss, quality of life and expansion of choices. Resident needs assistance with eating d/t [due to] vision limitations. R32's CP further indicated a long term goal of No significant weight changes will be observed .wt [weight] gain desirable. R32's CP…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify and monitor new bruising at the fistula site for 1 of 1 residents reviewed for dialysis. Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 was cognitively intact and had diagnoses of end stage kidney disease and hypertension. Furthermore R60's MDS indicated R60 was dependent on renal dialysis (treatment to filter the blood when kidneys are not functioning). R60's care plan revised 11/20/24, indicated R60 required hemodialysis three times a week and had a left arm fistula for access. Interventions included staff monitoring access site for bleeding or signs of infection and to notify dialysis/provider pf concerns. A review of R60's provider and nursing orders on 1/7/2025, indicated the following: -on 11/11/24, indicated R60 required fistualgram site monitoring three times a day and to notify the provider for increased pain, redness and/or swelling at site. -on 11/11/24, R60 required staff to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    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 dietary preferences were accommodated for 1 of 1 resident (R17) reviewed for food preferences. Findings include: R17's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have behaviors, did not reject cares, required setup or clean-up assistance with eating, had malnutrition or was at risk for malnutrition, morbid obesity, diabetes, did not have signs or symptoms of a swallowing disorder, did not have weight loss or gain, was not on a therapeutic or mechanically altered diet. R17's care plan dated 11/12/24, indicated R17 required a regular diet, had a history of gastric bypass in 2004, malabsorption, and was open to additional weight loss or maintenance and interventions included, R17 requested small portions, and wanted just milk and cereal/breakfast bar for the morning meal. R17's physician's orders form indicated the following orders: • 11/10/24, weekly weights for 4 weeks then change to monthly…

    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 · D2024-01-05 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 follow standard of practice when cardiopulmonary resuscitation (CPR) (compressing the chest to pump blood through the body and blowing air into a persons lungs in attempt to revive a person with no pulse who is not breathing) was initiated on a resident who displayed signs of rigor mortis (the stiffening of the joints and muscles of a body after death) for 1 of 1 resident reviewed for death. R1's minimum data set (MDS) dated [DATE], indicated R1 had died in the facility on [DATE]. R1's diagnoses included acute osteomyelitis (infection of a bone) of left ankle and foot, end stage renal disease (kidney failure), gangrene (death of tissues in the body), non-pressure chronic ulcer (open wound) of leg, peripheral vascular disease (blood circulation disorder), atrial fibrillation (irregular heart beat), hypertension (high blood pressure), chronic obstructive pulmonary disease, and hyperlipidemia (high cholesterol). R1's Provider Order for Life…

    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 · D2023-11-09 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to allow active resident and resident representative participation in the development and review of care plan for 1 of 1 resident (R59) that was a new admission. Findings include: R59's undated Face Sheet identified an admission date of 10/12/23. R59's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no rejection of care or behaviors. Diagnoses included dementia, depression and schizophrenia. Antipsychotic medications were received seven out of seven days. R59's preferences included very important to have family or close friend involved in discussions about her care. R59's Care Plan dated 11/2/23, identified N/A (non-applicable) next to the headings Last Care Conferences and Next Care Conference. R59's Observation History dated 10/12/23 through 11/9/23, lacked documentation of a care conference form. R59's Progress Notes dated 10/12/23 through 11/9/23, lacked documentation of a care conference. R59 declined an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 clean and maintain resident's wheelchairs for 1 of 1 resident (R23). Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had severely impaired cognition, a diagnosis of unspecified dementia with behavioral disturbance, and required extensive assistance with all activities of daily living (ADL). R23's nursing assistant care sheet (undated) indicated, R23 required total assistance of 1 staff and used a wheelchair for mobility. During observation on 11/06/23 at 1:23 p.m., R23 was sitting in his room in his wheelchair. There were multiple food stains on both sides of the seat cushion and excessive amounts of dried food on the bars of the wheelchair, the wheels, and the wheelchair brakes. In addition both of the arm rests had multiple tears. During observation on 11/7/23 at 9:35 a.m., R23 was sitting in his room in his wheelchair. There were multiple food stains on both sides of the seat cushion and excessive…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents that were prescribed psychotropic medications were monitored for target behaviors for 1 of 1 newly admitted resident (R59) reviewed for unnecessary medications. Findings include: R59's undated Face Sheet identified an admission date of 10/12/23. R59's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no rejection of care or behaviors. Diagnoses included dementia, depression and schizophrenia. Antipsychotic medications were received seven out of seven days. R59's Care Plan dated 11/2/23, lacked identification of target behaviors related to psychotropic medications. R59's Point of Care History (nursing assistant interventions) dated 10/7/23 through 11/7/23, lacked documentation behaviors had occurred. R59's Physician Order Report dated 10/7/23 through 11/7/23, identified the following: 1. Effective 10/12/23, olanzapine (antipsychotic medication) 2.5 milligrams (mg) tablet every…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CASSIA — 16 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 4 of 54.4-0.4 vs chain
Health inspection 3 of 53.7-0.7 vs chain
Staffing 5 of 54.8+0.2 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 15 homes this chain runs (chain average 4.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ELIM CARE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/25/1995
CASSIAOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/2018
ADDINGTON, JONIndividualCORPORATE DIRECTORsince 01/01/2025
ADERINKOMI, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2025
NUSS, PATRICKIndividualCORPORATE DIRECTORsince 01/01/2018
VLAMINCK, LORESIndividualCORPORATE DIRECTORsince 01/01/2025
WEBER-DANIELS, NICOLETTEIndividualCORPORATE DIRECTORsince 01/01/2025
BRADY, JAIMEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
BROWN, ANGELAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2018
KERN, MATTHEWIndividualCORPORATE OFFICERsince 10/01/2025
LIBBON, PAULIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
MASON, KRISSAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
STADTHERR, SEELOCHANIIndividualCORPORATE OFFICERsince 01/01/2018
YOUNGQUIST, KATHRYNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2001
ALBRECHT, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/05/1998
ALMSTED, KRISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/15/2025
BALDWIN, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/28/1998
SCHWENSEN, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2026
SONNTAG, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
THOMPSON, LAURIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/15/2021
VOGEL, MARISSAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/11/2017

CMS files one row per role, so the 34 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.2M
Net patient revenuemost recent cost report
+4.1%
Operating marginrevenue minus expenses
$1.7M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 9%Other / private 35%

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$475per resident / day
operating cost
$14,429per month
≈ monthly operating cost
$495per 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 245381. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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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