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Edenbrook Of Edina

6200 Xerxes Avenue South, Minneapolis, MN 55423 · For profit - Limited Liability company · 80 certified beds · (952) 925-8500 Medicare & Medicaid certified

Call the home — (952) 925-8500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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)

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.

3/5
CMS overall
3 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 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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
7380 France Ave S STE 215 Ste 215 · (952) 831-4222 · Call to confirm hours
Pharmacy
6401 France Ave S · (952) 924-1400 · Call to confirm hours
Grocery
6228 Penn Ave S · (612) 861-1881 · Call to confirm hours
Park
6498 Upton Ave S · (612) 861-9385 · 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 5 of 5
Long-stay residentspeople who live here 5 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 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased10.5%18.2%15.4%better
Long-stay residents who lose too much weight1.7%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.5%2.6%2.0%worse
Long-stay residents with depressive symptoms4.1%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.9%4.0%3.3%better
Long-stay residents whose ability to walk worsened15.4%20.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.1%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers2.0%5.2%4.7%better
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 table16.1%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.7%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine95.6%82.7%79.4%better
Short-stay residents rehospitalized after admission19.8%23.5%22.6%better
Short-stay residents with an outpatient ER visit10.1%14.8%12.0%better

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

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

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

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

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

55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.9%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
75.7%U.S. median 56.6%
Met the expected recovery
0.58U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.32hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 75.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNF55.9%CMS range 47.5–66.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.0–16.110.7%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 discharge75.7%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 discharge64.9%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 discharge67.6%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 identified100.0%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 setting90.5%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 discharge88.2%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 hospitalization8.9%CMS range 5.3–15.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

1.11
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.03
Aide hours/ resident / day
4.01
Total nurse hours/ resident / day
0.84
RN hoursweekends
38.3%
Total nursing turnover
42.1%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 68.0 residents a day — about 85% occupied, or roughly 12 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.11 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.59 hrs/resident/day on weekends vs 4.18 on weekdays — 14% thinner on weekends. RN hours go from 1.21 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-01-22)
2
at the previous standard inspection (2024-10-31)

Deficiencies are more than at the previous inspection — worsening. 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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2026-01-09 · 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 implement a fall management program which included development and implementation of care plans, comprehensive fall analysis for root causes, and implementation of appropriate fall interventions to prevent and/or reduce the likelihood of future falls for 5 of 5 residents (R1 had one unwitnessed fall with major injury, R6 who had four unwitnessed falls one with major injury, R2 had 8 unwitnessed falls, R3 had 4 unwitnessed falls, and R4 had 10 unwitnessed falls) who had an identified risk for falls. This resulted in actual harm for R6 who suffered a left tibial fracture and hospitalization and actual harm for R1 when she sustained a spinal fracture and hospitalization. Findings include R6 R6's face sheet dated 1/7/26, identified diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right side, epilepsy (brain disorder causing…

    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 before2026-01-22 · 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 comprehensively assess for safe self-administration and storage of medications and failed to obtain a physician order for 2 of 3 residents (R24 and R50) reviewed for self-administration of medications.Findings include:R24's quarterly minimum data set (MDS) dated [DATE], included R24 was cognitively intact. R24's diagnoses included respiratory failure, chronic obstructive respiratory failure (a progressive lung disease that damages airways resulting to shortness of breath, mucus production, wheezing and chest tightness).R24's Order Summary Report dated 1/21/26, included an order for an albuterol sulfate inhaler (Ventolin HFA Inhalation Aerosol Solution) with instructions to take 2 puffs every 4 hours as needed.R24's self-administration assessment dated [DATE], included the selection of Not Applicable for the question regarding the resident's ability to store medications securely in his room. The results of the assessment included resident…

    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 · D2026-01-22 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 record review and interviews, the facility failed to ensure the skilled nursing facility Advanced Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary notifications. Findings include:R59's Perspective payment system Part A Discharge Minimum Data Set (MDS) dated [DATE], indicated R59 was admitted on [DATE] and Medicare Part A discharge date of 8/13/25.R59's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), informed R59 services would end on 8/14/25. However, this notice was given outside of the 48 hours prior to services ending requirement and was provided on 9/22/25.On 1/22/26 at 1:14 p.m. the MDS Coordinator (MDSC) stated the facility had struggled to identify the correct payer source for the resident and once they did, they had R59 sign an SNFABN, however they were unable to locate the form and had R59 sign a new SNFABN on 9/22/25. The MDSC confirmed it was outside the required 48 hours prior to the end of services.On 1/22/25 at…

    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 · D2026-01-22 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure ordered as needed (PRN) psychotropic medications were limited to a 14-day time period for 1 or 5 residents (R34) reviewed for unnecessary medications. Findings include:R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 was admitted on [DATE], was severely cognitively impaired and had the following diagnoses: hypertension, renal insufficiency, hyperlipidemia, dementia, anxiety, and depression. R34's order summary report dated 1/22/26, indicated R34 was currently prescribed Lorazepam 0.5mg (milligrams) orally every 1-hour PRN with a start date of 12/17/25. The order lacked an end date. R34's medical record lacked evidence of rationale to continue past the required 14-day timeframe for psychotropic medications.On 1/22/26 at 1:15 p.m. the director of nursing confirmed they were aware of the 14-day time frame for psychotropic medications and stated they missed it with R34 and were currently working on a new process to ensure it does…

    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 before2026-01-22 · 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 follow physician orders for 1 of 2 residents (R3) reviewed for nutrition.Findings include:R3's admission minimum data set (MDS) dated [DATE], included R3 was severely cognitively impaired. R3 had diagnoses of diabetes, hyponatremia (happens when excessive water accumulates relative to sodium), and hypertension (high blood pressure).R3's physician order summary report dated 1/22/26, included an order for daily weights due to heart failure with instruction to update the provider with a weight gain of 3 pounds (lbs) or greater in 24 hours or 5 pounds in one week unless otherwise directed by a provider. Order was started on 10/25/25.R3's weights outside of these parameters were as follows:10/28/25: 218.0 lbs10/29/25: 228.4 lbs11/18/25: 212.2 lbs11/19/25: 221.1 lbs11/28/25: 204.9 lbs11/30/25: 213.8 lbs12/7/25: 201.0 lbs12/8/25: 208.6 lbs12/10/25: 206.0 lbs12/12/25: 214.1 lbs12/24/25: 200.2 lbs12/26/25: 245.6 lbs1/20/26: 187.5 lbs1/21/26: 203.0 lbs Review…

    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 · F2026-01-09 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to increase in resident falls by developing and implementing action plans for process improvement. This had the potential to affect all 60 residents that resident in the facility. Findings include:Based on review of facility records, Quality Review minutes, QAPI documentation, incident reports, and staff interviews, the facility failed to implement its QAPI program in accordance with its written plan, including failure to identify falls as a high-risk and problem-prone area, failure to initiate and sustain Performance Improvement Projects, failure to conduct comprehensive root cause analysis, and failure to develop, implement, and monitor effective corrective actions to prevent recurrence. Findings include The facility's QAPI Plan states that Edenbrook of Edina will conduct Performance Improvement Projects (PIPs) that are designed to take a systematic approach to revise and improve care or services…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · 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 document review, the facility failed to timely report to State Agency (SA) falls with serious injury for 2 of 2 residents (R1, R6) who had falls without implementation of appropriate fall interventions to prevent/mitigate risk of recurrent falls. Findings include: R1's face sheet dated 12/31/25, identified diagnoses of Parkinson's disease (a progressive nervous system disorder affecting movement that caused tremors, stiffness, slow movement, and balance issues) with dyskinesia (involuntary, erratic muscle movements), congestive heart failure (a condition where the heart does not pump blood as well as it should), atrial flutter (a fast heart rhythm), and diabetes mellitus (a condition that affects how the body uses sugar as fuel). R1's Morse fall scale (fall risk assessment) dated 12/5/25, indicated R1 had not fallen in the past 3 months, had more than one diagnosis, normal gait, and overestimated or forgets her limits. R1 was at moderate risk for falling. R1's admission Minimum Data Set…

    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 · D2026-01-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to revise the care plan for 2 of 5 residents (R4.R6) who were reviewed for accidents/falls.Findings include:R4's face sheet dated 12/31/25, indicated R4 was admitted on [DATE]. Diagnoses included encounter for orthopedic aftercare, acute respiratory failure with hypoxia, seizures, mechanical complications of indwelling urethral catheter, insomnia, bipolar disorder, obstructive and reflux uropathy, presence of right artificial knee joint, heart failure, bilateral primary osteoarthritis of knee, myalgia (muscle pain), psychoactive substance abuse and reduced mobility. R4 fall focus care plan dated 11/3/25, identified R4 was high-risk for falls related to acute respiratory failure with hypoxia, sepsis, seizures, post-traumatic stress disorder, bipolar disorder, history of pulmonary embolism, benign prostatic hyperplasia without lower urinary tract symptoms. R4's goal was for her injury related to falls will heal without complication by 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · 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 record review the facility failed to provide a clean, comfortable, and homelike environment for 2 of 3 residents assessed (R1 and R3). R1's room was observed having the bed made over a urine-soiled facility bath blanket. R3's room was cluttered with facility supplies covering up furniture and clean supplies found on the floor. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 10 indicating R1 had moderate cognitive impairment. R1 required maximum assistance with toileting hygiene, dressing, personal hygiene and transferring. R1's pertinent diagnoses were left femur (hip) fracture, chronic respiratory failure, and unspecified intellectual disabilities. R1 was frequently incontinent of bowel and bladder. R1's care plan revision dated 11/13/24 indicated R1 had functional bladder incontinence. Her interventions were to clean peri-area with each incontinent episode. Monitor for signs 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · 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 interview and document review the facility failed to ensure the comprehensive care plan was developed to implement cares and services for a leg prosthetic for 1 of 1 resident (R3) reviewed. R3's care plan did not have any person-centered details for R3's prosthetic placement or use. In addition, R3's comprehensive assessment did not indicate R3 had a leg prosthetic. Findings include: R3's significant change MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 had no cognitive impairment. R3's behavior status indicated he rejected cares 1-3 days out of 7. R3 was totally dependent upon staff for oral hygiene, toileting hygiene, showering, lower body dressing, personal hygiene and transferring. R3 was always incontinent of bowel and bladder. R3 was not on a bowel toileting program. R3's pertinent diagnoses were chronic congestive heart failure, acute respiratory failure, acute pulmonary edema (fluid in the lungs), type II Diabetes, morbid obesity, absence of left foot, contracture (shortening…

    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 · D2024-12-31 · 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 interview and record review the facility failed to meet a resident needs and choices to perform activities of daily living of toileting for 1 of 3 residents (R3) reviewed when R3 wore an incontinent brief for toileting. R3 had a below the knee leg prosthesis and was unable to use his preferred method of toileting due to staff not able to apply the prosthesis in a timely manner to transfer R3 to the toilet or commode chair (a portable toilet chair) as indicated on R3's care plan. Findings include: R3's significant change MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 had no cognitive impairment. R3's behavior status indicated he rejected cares 1-3 days out of 7. R3 was totally dependent upon staff for oral hygiene, toileting hygiene, showering, lower body dressing, personal hygiene and transferring. R3 was always incontinent of bowel and bladder. R3 was not on a bowel toileting program. R3's pertinent diagnoses were chronic congestive heart failure, acute respiratory failure, acute…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-10-31 · 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 a self-administration of medications (SAM) assessment and a physician's order was completed to allow a resident to safely administer their own medication for 3 of 4 residents (R263, R15, R54) observed with unattended medication. Findings include: R263's admission Record dated 10/31/24, identified admission on [DATE], with diagnoses including orthopedic aftercare following surgical amputation and type one diabetes mellitus. R263's undated assessments list lacked a SAM evaluation for insulin until 10/28/24. R653's baseline care plan and comprehensive care plan dated 10/26/24, identified he could communicate easily and understand staff, however, lacked an assessment for SAM of home insulin until 10/28/24. R263's progress notes lacked assessment of SAM for home insulin. The progress notes lacked determination of R263's clinical appropriateness to SAM insulin, or involvement of the interdisciplinary team (IDT), including 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · 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 and interview, the facility failed to provide a homelike environment for 1 of 1 resident (R27) reviewed who had an unclean tube feeding pole. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was severely cognitively impaired, dependent on staff for all activities of daily living, had diagnoses of traumatic brain injury and dementia, and indicated they had a feeding tube through which they received more than 50% of their nutrition. During observation on 10/28/24 at 2:14 p.m., R27 was in his room with tube feeding running. The tube feeding pump was attached to a pole, which had smudged areas down most of the pole. The legs of the base had multiple drops and streaks of tannish colored substance which were scattered and approximately covered a quarter of the surface area of two legs. One of the legs of the base had a thick area approximately three by two and a half inches of crusted tannish colored substance, and the floor had four tannish colored drops…

    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 · Dcited before2024-10-15 · 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 observation, interview and document review, the facility failed to provide treatment to a skin tear and documented it had been completed for 1 of 4 residents (R3) reviewed for wound care. In addition, the facility falsely documented wound care was being provided for 2 of 4 residents (R4, R5) reviewed for wound care whose wounds had been resolved. Findings include: R3 R3's Face Sheet indicated R5 had diagnoses of paraplegia (paralysis caused by spinal injury or disease), peripheral vascular disease (abnormal narrowing of arteries other than those that supply the heart or brain), and methicillin resistant staphylococcus aureus infection (MRSA, a type of bacteria that has developed resistance to antibiotics). R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 was cognitively intact and required the assist of two staff for toileting, transfers, and bed mobility. R3's progress note dated 7/20/24, indicated R3 was noted to have a skin tear on his right lower leg. R3 stated it may have been from…

    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 · D2024-10-15 · 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 record review, the facility failed to utilize enhanced barrier precautions (EBP) for 2 of 5 residents (R3) observed for personal cares and wound care treatments. Findings include: Per the Centers for Disease Control (CDC) dated 6/28/24: EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted multi-drug resistant organisms (MDRO) (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device. High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. R3's Face Sheet indicated R5 had diagnoses of paraplegia (paralysis caused by…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to protect a resident while an allegation of abuse was being investigated for 1 of 3 (R1) residents reviewed for abuse. Findings include: R1's Medicare 5 day Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, and required the assistance of one staff for eating, transferring, toileting, and bed mobility. R1's Face Sheet undated indicated R1 had diagnoses of type II diabetes, depression, anxiety, cognitive communication deficit, weakness, and dementia. R1's Special Instructions dated 8/5/24, in the electronic health record directed staff to complete Cares in Pairs (two staff present when completing cares). On 8/5/24 at 9:41 a.m., R1 was interviewed. R1 stated staff were rough with him, Yeah they just got real rough. They grabbed me by my shirt and lifted me up. It did hurt. On 8/5/24 at 10:02 a.m., R1's power of attorney (POA) stated a staff member yanked R1 up by his left arm while he was asleep to change…

    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 before2024-06-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to awake staff on the overnight shift to provide adequate supervision and care of residents for 1 of 3 residents (R1) when R1 called 911 due to pain and the need to use the bathroom. Findings include: R1's Medical Diagnoses list undated, included surgical aftercare following surgery secondary to malignant neoplasm of the colon (colon cancer) and ileostomy (a surgical opening in the small intestine which drains into an external bag). R1's care plan dated 6/13/24 directed to anticipate resident's need for pain relief, respond immediately to any complaint of pain, and administer medication for pain management. R1's care plan directed two staff to assist to the toilet due to reduced mobility status. The care plan directed R1 used a disposable brief, and staff were to provide incontinence cares after each episode of bladder incontinence. On 6/20/24 at 10:48 a.m., the director of nursing (DON) stated the facility became aware of allegations of staff sleeping on the night shift, when the police were called to the facility on…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and document review, the facility failed to have a designated charge nurse for each shift. Findings include: On 6/20/24 at 12:43 licensed practical nurse (LPN)-A stated there was not a charge nurse assigned the night of 6/14/24. LPN-A stated, Every nurse is in charge. On 6/21/24 at 2:18 p.m., the administrator stated via email, The nurses in the building are in charge. She stated the director of nursing (DON) is on call 24/7 for any clinical concerns. On 6/21/24 at 2:45 p.m., DON stated there was not a designated charge nurse each shift. A policy was requested regarding having a designated charge nurse for each shift. This was not provided.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-11 · 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 report alleged violations of abuse was reported immediately, but no later than 2 hours after the allegation is made State Agency for one of one resident (R1) reviewed when a police officer visited the facility to investigate an allegation of abuse. for reporting of alleged violations of mistreatment, exploitation, neglect, or abuse. Law enforcement visited R1 due to allegations of maltreatment and stated to the Director of Nursing (DON) they were there for allegations of maltreatment and the facility did not report the allegations of maltreatment. Findings include: R1's admission Record printed on 6/10/24 indicated R1 was admitted to the facility on [DATE]. R1's diagnoses include post-traumatic stress disorder, dependence on renal dialysis, need for assistance with personal care, reduced mobility, borderline personality disorder, and major depressive disorder with severe psychotic symptoms. R1's progress note dated 11/3/22 indicated R1 was admitted 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-11 · 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 interview and record review, the facility failed to investigate a report of abuse for one of one resident (R1) reviewed for response to allegations of abuse when a police officer visited the facility to investigate an allegation of abuse. Findings include: R1's admission Record printed on 6/10/24 indicated R1 was admitted to the facility on [DATE]. R1's diagnoses include post-traumatic stress disorder, dependence on renal dialysis, need for assistance with personal care, reduced mobility, borderline personality disorder, and major depressive disorder with severe psychotic symptoms. R1's progress note dated 11/3/22 indicated R1 was admitted to the facility with a primary diagnosis of chronic failure renal end stage renal disease dialysis dependent. R1's brief interview for mental status (BIMS) dated 5/14/24 indicated R1 had a score of 14, which indicated R1 was cognitively intact. R1's police report dated 6/6/24 indicated law enforcement went to visit R1 due to reports the nursing staff was grabbing her…

    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 · D2024-03-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure R1 was allowed to exercise rights consistent with the comprehensive assessment and plan of care for 1 of 3 residents (R1) reviewed. R1 was her own representative who wanted to leave the facility after having smoking privileges revoked, was not an elopement risk, did not have dementia, and was not given assistance getting her needs met with her desire to leave. In addition, her smoking privileges were revoked without assistance to manage a safe smoking plan at the facility or assistance with smoking cessation tools. Findings include: R1's clinical resident profile dated 8/11/23 indicated R1 was her own responsible party. R1's care plan dated 8/18/23 indicated R1 was an elopement risk/wanderer and at risk to leave the facility without notice unauthorized related to history of repeatedly trying to exit the unit through the stairwell. R1's interventions were a discussion of the facility expectations: Signing out before leaving/out on pass 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-21 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 maintain respect and dignity for personal possessions for 1 of 3 resident's (R1) reviewed who had her room searched and items removed without consent. Findings include: R1's clinical resident profile dated 8/11/23 indicated R1 was her own responsible party. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 13 indicating R1 was cognitively intact. R1's pertinent diagnoses were chronic diastolic (congestive) heart failure, pressure ulcer of the left heel, dependence on renal dialysis and long term (current) use of insulin. R1's elopement risk assessment dated [DATE] at 2:35 p.m. indicated R1 was at low risk for elopement. R1's mental status indicated she could follow instructions, could communicate, could move without assistance while in a wheelchair. R1 did not have a diagnosis of dementia and was cognitively intact. R1 had wandered/eloped/exit seeking within the past month.…

    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 · Dcited before2023-12-29 · 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 a resident was assessed to self-administer medications (SAM) for 1 of 1 resident (R171) reviewed whose medications were left in the resident room during medication administration. Findings include: R171's diagnosis list dated 12/15/23, identified alcoholic hepatitis, toxic effects of unspecified substance, anxiety, and depression. R171's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and set-up assistance was required at meals. R171's care plan dated 12/18/23, lacked a focus area for SAM. R171's order summary dated 12/28/23, lacked direction related to SAM. R171's order summary identified the following morning medications with a start date of 12/15/23: 1. folic acid 1 milligram (mg) tablet 2. gabapentin 300 mg capsule tablet 3. furosemide 20 mg tablet 4. prednisolone15 mg/5 milliliters (ml) solution, give 19.5 mg 5. thiamine 100 mg tablet 6. spironolactone 50 mg tablet 7. vitamin D3 25 microgram (mcg),…

    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 · D2023-12-29 · 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 ensure routine bathing and hair washing was offered or provided to promote good hygiene for 2 of 3 residents (R13, R172), and failed to ensure oral cares were offered or provided for 1 of 3 residents (R46) reviewed for activities of daily living (ADLs) and who were dependent on staff for their cares. Findings include: R13 R13's significant change Minimum Data Set (MDS) dated [DATE], indicated she was severely cognitively impaired, required substantial/maximal assistance with showering/bathing, and did not reject cares. R13's care plan reviewed 9/19/23, identified R13 required assist of one staff for bathing/showering. R13's Order Summary Report dated 12/26/23, included shower/bath day was scheduled for Saturday. R13's ADL task documentation for the dates 11/30/23 - 12/27/23, included R13 was totally dependent on staff on 12/2/23 and 12/23/23, and was documented as Not Applicable on 12/16/23. During observation on 12/26/23 at 12:58 p.m.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-29 · 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 monitor weights as ordered for 1 of 1 residents (R13) reviewed for weight loss. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], indicated they were severely cognitively impaired, diagnoses of malnutrition, heart failure, edema, high blood pressure, kidney disease, and diabetes, had no behavioral symptoms, weighed 158 pounds (lbs.), and had no or unknown weight loss. R13's Care Area Triggers Summary indicated R13 had highly impaired visual function, severe cognitive impairment, and nutritional concerns. R13's care plan dated 9/15/23, indicated R13 had the potential for altered nutritional status and directed staff to weigh R13 per facility policy or as ordered, and notify provider per order with significant changes. R13's Order Summary Report dated 12/26/23, included complete vital signs and weight on bath day, every Saturday on day shift, starting 9/26/23. The report also included weekly weight every day shift on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-29 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the necessary services for the behavioral health needs for 1 of 1 resident (R186) reviewed for mood and behavior. Findings Include: R171's admission Minimum Data Set (MDS) dated [DATE], identified R171 was cognitively intact. R171's diagnoses included anxiety, depression, agoraphobia with panic disorder (fear of and avoids places or situations that might cause panic and feelings of being trapped, helpless or embarrassed), alcohol use with alcohol induced disorder and toxic effect of unspecified substance. R171's care plan (CP) dated 12/18/23, identified R171 had potential psychosocial well-being related to diagnoses of depression and alcohol abuse and instructed staff to consult with pastoral care, social services, and psych services. R171's CP further identified R171 as vulnerable and directed staff to evaluate need for psychological referral and evaluation. R171's psychotropic Care Area Assessment (CAA) dated 12/18/23, identified R171 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 · D2023-12-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 5 residents (R46) reviewed for unnecessary medications. Findings include: R46's significant change Minimum Data Set, dated [DATE], indicated R46 was cognitively intact and had a diagnosis of hypertension (HTN- high blood pressure) R46's Consultation Report dated 8/14/23, included R46 had a Hydralazine PRN (as needed) order for HTN and did not list a blood pressure parameter for when to administer it and requested provider clarification. R46's Consultation Report dated 9/12/23, included R46 had a Hydralazine PRN order for HTN without parameters listed. Please clarify with provider and add parameters for medication use. Second request - see 8/14 recommendation for initial recommendation. R46's Order Summary Report dated 12/28/23, included Hydralazine HCl Oral Tablet 50 milligrams (mg), give 1 tablet every 8 hours as needed for HTN starting 7/26/23 and lacked parameters for use. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-29 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 orders were entered appropriately and carried out for a urinary analysis and culture (UA/UC) for processing in a timely manner for 1 of 2 residents (R169) reviewed for urinary tract infections (UTI). Findings include: R169's admission Minimum Data Set (MDS), dated [DATE], identified R169 had moderately impaired cognition and was occasionally incontinent of urine. Further, the MDS indicated R169 did not have a current or previous (within 30 days) UTI. R169's care plan, dated 12/15/23, identified R169 required one person assist for personal hygiene and toileting. R169's admission LOEBS infection criteria dated 12/15/23, identified R169 was prescribed an antibiotic due to high risk protocol for prophylaxis. R169's physician order dated 12/21/23 at 6:00 p.m., instructed staff to collect urine for a UA/UC. The order was noted by RN-B on 12/21/23. During interview on 12/26/23 at 5:23 p.m., R169 stated symptoms of burning and bleeding 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-29 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care 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 ensure dental status was accurately assessed and routine dental services were provided for 1 of 2 residents (R46) reviewed for dental concerns, who had broken/chipped teeth in poor condition. Findings include: R46's significant change Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, had diagnoses of stroke, hemiplegia (a severe or complete loss of strength or paralysis on one side of the body), hemiparesis (a mild loss of strength on one side of the body), cancer, diabetes, and used a gastric tube for some nutrients and medications, and was completely dependent on staff for oral hygiene. The MDS indicated R46 had no broken or loosely fitting dentures, no obvious or likely cavities or broken teeth, no inflamed or bleeding gums or loose teeth, no mouth or facial pain, discomfort, or difficulty chewing. R46's Dental Care Area Assessment was not triggered. R46's admission Screener dated 7/17/23, indicated R46 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

“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 EDEN SENIOR CARE — 21 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 3 of 52.6+0.4 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 4 of 53.1+0.9 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 20 homes this chain runs (chain average 2.6★, 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
FEINSTEIN, DANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 01/06/2017
POLSTEIN, MORDECHAIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER20%since 01/06/2017
STESEL, MAXIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER55%since 01/06/2017
DOUGHTY, JOHNIndividualW-2 MANAGING EMPLOYEEsince 06/30/2017
RICE, PAMELAIndividualW-2 MANAGING EMPLOYEEsince 06/30/2017

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$8.6M
Net patient revenuemost recent cost report
-6.9%
Operating marginrevenue minus expenses
$577K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 7%Other / private 27%

This home reported $577K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$387per resident / day
operating cost
$11,751per month
≈ monthly operating cost
$362per 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 245275. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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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