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Jones Harrison Residence

3700 Cedar Lake Avenue, Minneapolis, MN 55416 · Non profit - Corporation · 120 certified beds · (612) 920-2030 Medicare & Medicaid certified

Call the home — (612) 920-2030 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609, F0610) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • 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 (30) — 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) 5 of 5
Quality measuresSelf-reported by the facility 4 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3270 W Lake St · (612) 262-8890 · Call to confirm hours
Pharmacy
3240 W Lake St · (612) 922-8436 · Call to confirm hours
Grocery
3060 Excelsior Blvd · (612) 927-8141 · Call to confirm hours
Park
3113 W 28th St · (612) 230-6400 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 rating4★
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 increased9.5%18.2%15.4%better
Long-stay residents who lose too much weight4.1%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.2%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.1%2.6%2.0%worse
Long-stay residents with depressive symptoms7.0%4.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%4.0%3.3%better
Long-stay residents whose ability to walk worsened14.7%20.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication9.1%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine99.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.6%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control24.0%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.2%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication2.2%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine77.6%82.7%79.4%typical
Short-stay residents rehospitalized after admission27.9%23.5%22.6%worse
Short-stay residents with an outpatient ER visit3.8%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.901.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.501.901.80better

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.

47.4% 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 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.4%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
58.7%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 58.7% 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 75 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.4%CMS range 40.1–53.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.7–13.910.7%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 discharge58.7%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 discharge41.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.3%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 identified99.0%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 setting92.6%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 discharge100.0%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 stay1.0%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 worsened3.0%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 hospitalization5.8%CMS range 3.3–10.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 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

1.48
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.62
Aide hours/ resident / day
4.71
Total nurse hours/ resident / day
1.13
RN hoursweekends
28.4%
Total nursing turnover
46.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 107.9 residents a day — about 90% 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 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.48 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 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 4.35 hrs/resident/day on weekends vs 4.86 on weekdays — 10% thinner on weekends. RN hours go from 1.63 to 1.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

10
deficiencies at the latest standard inspection (2026-01-09)
7
at the previous standard inspection (2024-11-14)

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2026-07-02 · 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 and interview, the facility failed to ensure interventions to reduce the risk of falls were implemented for 1 of 3 residents (R1) reviewed for accidents. R1 fell from her bed when the nursing assistant (NA)-A repositioned her alone, R1's care planned interventions required two staff for repositioning. R1's fall resulted in a femur fracture with surgical intervention.Findings include: R1's care plan dated 12/15/26 indicated R1 required substantial assistance from two staff to assist and reposition every 2 hours. Substantial/maximum assistance of two staff for dressing assistance, bathing, and toilet use. R1 was able to determine when she has voided or had a bowel movement and would call for staff assistance when her incontinent brief required changing. R1's fall assessment dated [DATE] indicated R1 was a high fall risk. R1 was alert and oriented. R1 was chair bound and non-ambulatory. R1's quarterly minimum data set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS)…

    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 no plan of correction
  • Potential for harm · D2026-01-09 · 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 interview and document review the facility failed to ensure residents taking psychotropic medications had an appropriate clinical rationale for not attempting a gradual dose reduction of psychotropic medications, an appropriate diagnosis for use of antipsychotic medications, and non-pharmacological interventions were attempted and documented with as needed psychotropic use. The facility further failed to ensure behaviors were observed and documented to adequately justify psychotropic medication use. This had the ability to effect 3 of 5 residents (R63, R87 and R180) reviewed for unnecessary medications.Findings include:R63R63's quarterly Minimum Data Set (MDS), dated [DATE], indicated R63 was admitted to the care facility on 6/14/25 and had mild cognitive impairment. The MDS further indicated R63 received antipsychotic medication and antidepressant medication during the look-back period without a gradual dose reduction (GDR) attempted.R63's Order Summary Reported, dated 12/2/25, indicated R63 was 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 · 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 implement their written policy and procedure and ensure an allegation of sexual abuse was reported to the state agency for 1 of 2 residents (R81) reviewed for allegations of abuse.Findings include:R81's quarterly Minimum Data Set (MDS), dated [DATE], indicated R81 was admitted to the care facility on 7/22/23 and had severe cognitive impairment. The MDS further indicated R81 required partial to moderate assistance with most activities of daily living and required substantial assistance with toileting.R81's care plan, dated 7/16/25, indicated should resident report that she was sexually assaulted, staff should ensure resident is safe and report allegation to their supervisor immediately.R81's progress note, dated 12/14/25 at 11:25 a.m., indicated resident [R81] reported that she was sexually abused at night. Writer reported to daughter. Daughter ran the camera and reported two NAR [nursing assistants] changed resident and she went to sleep. Nothing…

    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 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 document review the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for 1 of 2 residents (R81) reviewed for allegations of abuse. Findings include:R81's quarterly Minimum Data Set (MDS), dated [DATE], indicated R81 was admitted to the care facility on 7/22/23 and had severe cognitive impairment. The MDS further indicated R81 required partial to moderate assistance with most activities of daily living and required substantial assistance with toileting.R81's care plan, dated 7/16/25, indicated should resident report that she was sexually assaulted, staff should ensure resident is safe and report allegation to their supervisor immediately.R81's progress note, dated 12/14/25, indicated resident [R81] reported that she was sexually abused at night. Writer reported to daughter. Daughter ran the camera and reported two NAR [nursing assistants] changed resident and she went to sleep. Nothing wrong happened to resident as per the resident daughter. Daughter said,…

    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 F0641 — isolated
    Ensure each resident receives an accurate 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 accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 residents (R18) reviewed for hospice.Findings include: During an observation on 1/5/26 at 1:41 p.m., R18 was observed lying in bed with her eyes closed. During a follow up interview and observation on 01/7/26 at 8:50 a.m., R18 was observed in the dining room. R18 smiled but did not answer questions. R18's quarterly MDS assessment, dated 11/1/25, identified R18 had severely impaired cognition. Diagnoses included dementia (significant loss of memory, thinking and reasoning skills), atrial fibrillation (an irregular and often rapid heart rhythm), dysphagia (difficulty swallowing), chronic pain and hemiplegia (paralysis affecting one side of the body). The MDS contained section O which contained a section hospice care which was marked no indicating R18 did not receive hospice services. R18's orders, printed 1/9/26, included the following order:-ok for hospice to evaluate, treat and accept with a start date of 8/1/24-call hospice in case of an emergency…

    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 before2026-01-09 · 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 a resident's nails were kept clean and trim for 1 of 3 residents (R90) reviewed for activities of daily living. Findings include: R90's quarterly Minimum Data Set (MDS), dated [DATE], indicated R90 was cognitively intact, had upper and lower extremity impairments on one side and required substantial to maximum assistance with activities of daily living. R90's care plan, dated 7/10/24, indicated R90 had limited physical mobility and self-care performance deficit related to hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness or reduced strength on one side of the body) following a cerebral infarction (stroke) affecting his right side, required assist of two staff with bathing/showering, and directed staff to provide nail care as needed. During observation and interview on 1/5/26 at 4:25 p.m., R90 had fingernails approximately 1/4 inch long with dark matter underneath them. R90 looked down at his nails 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 · Dcited before2026-01-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a medication order, written in error and without documented justification was appropriately questions and doubled checked before implementing and administering the medication multiple times for 1 of 1 resident (R108) reviewed for unnecessary medications. Findings include:R108's quarterly MDS, dated [DATE], indicated R108 was admitted to the care facility on [DATE] and has severe cognitive impairment.R108's EMR contained an order, dated [DATE], for lorazepam (an antianxiety medication) 0.5 mg every 2 hours for anxiety, ordered by hospice. The EMR also contained an order for lorazepam 0.5mg every 2 hours as needed for 14 days, dated [DATE] - [DATE] and a second as needed order dated [DATE] and discontinued on [DATE].R108's medication administration records indicated R108 had received 6 doses of as needed lorazepam in [DATE] and 1 dose in [DATE] between [DATE] and [DATE]. Between [DATE] and [DATE], R108 received a total of 11 doses of scheduled…

    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 before2026-01-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 assess and develop non-pharmacological interventions to promote comfort for 1 of 2 residents (R4) reviewed for pain management.Findings include: R4's admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated R4 had intact cognition. Diagnoses included the following: rheumatoid arthritis (chronic autoimmune disease where the immune system attacks joint linings, causing pain, swelling, stiffness, fatigues and damage to joints), Sjogren's syndrome (chronic autoimmune disease which can cause symptoms including fatigue and joint pain), arthrodesisis status (indicated that patient has undergone surgical joint fusion), muscle weakness, and chronic pain. Further the assessment identified R4 received PRN (as needed) pain medications and received non-medication interventions for pain. Furthermore, R4 identified she frequently had pain which occasionally effects sleep, interferes with day-to day activities and rated pain at a 10 out of 10 on a pain scale with 10 as the worst pain. During an interview 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 · Dcited before2026-01-09 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review the facility failed to develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R2) residents reviewed for trauma-informed care.Findings include: R2's quarterly Minimum Data Set (MDS) assessment, dated 11/26/25, indicated R4 had severely impaired cognition. Diagnoses included: PTSD, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, depression, dementia (significant loss of memory, thinking and reasoning skills), and seizure disorder (condition where the brain has abnormal electrical activity suddenly that temporarily disrupts normal function). R2's Psychosocial History Assessment, dated 11/19/25, identified through a question with a radio-button answered yes that R2 experienced any significant life events that continued to affect R2's life. The assessment form disclosed R2 stated long ago and did not specify further…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · 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

    Based on observation, interview, and document review, the facility failed to ensure laundry was laundered according to standard infection control practices, with the potential to affect all 116 residents residing in the facility. Findings include:The Centers for Disease Control and Prevention's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities: Laundry and Bedding resource dated 1/8/24, indicated that damp laundry should not be left in machines overnight. During an observation and interview on 1/8/25 at 12:45 p.m., multiple (greater than ten) cloth mop heads were observed in the laundry machine. Laundry aide (LA)-A stated that the mop heads, cleaning rags, microfiber cloths, and clothing protectors would be brought down to the laundry room throughout the day. The non-laundry staff would then start the laundry machine in the evening. The non-laundry staff would not assist in moving the clothing to the drying machine. The laundry aide confirmed that the usual practice was for the laundry listed above to be cleaned, left wet in the washing machine…

    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 before2025-07-24 · 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 assess a resident timely after a change of condition for 1 of 3 (R1) residents reviewed for change in condition.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses including paraplegia, urinary tract infection, and protein-calorie malnutrition. R1's care plan dated 7/4/25, indicated R1 was usually able to identify the need to have incontinent product changed and was able to utilize the call light to request assistance. R1's preference was to have incontinent product checked at 4 am only. A nurse's note written by registered nurse (RN)-A on 7/14/25 at 6:46 a.m., indicated R1 was alert and oriented to baseline with no shortness of breath or respiratory distress noted or reported. R1 slept through the night. A nurse's note written by licensed practical nurse (LPN)-A on 7/14/25 at 6:59 a.m., indicated during report the outgoing nurse (RN-A) denied R1 had a change of condition and insisted R1 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
Show the remaining 19 citations
  • Potential for harm · D2025-07-09 · 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 identify a resident's highest level of wellbeing, develop individualized care plan interventions, involve the medical provider to review rejection of care, and develop new goals and treatment choices, for 2 out of 3 residents (R1 and R2) when both residents refused hygiene (washing face and hands, brushing hair and teeth), peri care (washing rectum and vaginal areas after incontinence), weekly bed baths, and reducing risk for developing pressure ulcers. In addition, R1 refused to let staff check her blood pressure (BP) required prior to giving medication, and monitoring R2's weight weekly as ordered. Findings include: R1's care plan dated 11/20/24, indicated she needed two staff to change her incontinent pad when soiled and transfer out of bed with a mechanical lift. Staff would do a sponge bath when unable to do a full bath or shower. She needed one staff member to turn from side to side in bed, dress, hygiene, and oral care. No indication she…

    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 · F2024-11-14 · 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 record review, the facility failed to test the levels of chemicals used on the three compartments sink to sanitize the pots used for meal preparation; failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk for cross contamination; and failed to properly monitor food temperatures before serving food to residents. These findings had the potential to affect all 102 residents, staff, and visitors, who consumed food prepared from the main production kitchen. Findings include: During observation and interview on 11/12/24 at 8:20 a.m., an initial kitchen tour was completed with culinary coordinator (CC) and the following items were identified: 1. A series of two white colored plastic bins were on the floor (wheeled) adjacent to the baking area. These were labeled for flour and sugar. However, the bin labeled for flour was approximately half full and a plastic, blue-colored scoop was present inside the bin and touching the flour. The handle was pointed upward from the product. CC opened the flour container…

    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 · D2024-11-14 · 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 ensure a sanitary and homelike environment for 1 of 1 residents (R55) who had dried feeding tube-like substance on their feeding tube pole, dresser, bed, and floor. Findings include: R55's quarterly Minimum Data Set (MDS) dated [DATE], indicated R55 had intact cognition and depended on staff for assistance with dressing, transferring, and bed mobility. The MDS indicated R55 received over 50 percent of her total calories through a feeding tube. R55's medication administration record (MAR) dated 11/1/24 indicated received daily feedings from 9 p.m. to 11 a.m. During an observation on 11/12/24 at 11:20 a.m., R55 was observed lying in bed on the left side of the room with a feeding pump attached to a pole to her right. To the right of the pole was a dresser and in front of the pole was a bedside table. The dresser had splatters of a light brown/yellow substance scattered over the side and front of the dresser. The light brown/yellow…

    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 before2024-11-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 document review, the facility failed to ensure care plan interventions were followed and new interventions were implemented in a timely manner when resident pain goals were not met for 1 of 1 residents (R44) to ensure comfort and reduce the risk of complications. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had intact cognition. The MDS indicated R44 was on a scheduled and as-needed (PRN) pain medication regimen and received non-pharmocological interventions for pain. The MDS indicated R44 had pain almost constantly over the past five days and it made it hard for R44 to sleep constantly and occasionally limited day-to-day activities. R44's care plan dated 6/5/24, indicated R44 had pain related to multiple factors including lumbar spinal stenosis (narrowing of the spinal canal causing pressure on the nerves) with radiculopathy (a pinched nerve), osteoarthritis (a joint disease that can cause pain stiffness or swelling), osteoporosis (weak…

    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 before2024-11-14 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of post traumatic stress disorder (PTSD) for 1 of 1 residents (R79) reviewed for trauma-informed care. Findings include: R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated R79 was [AGE] years old, was cognitively intact and the MDS further indicated R79 was widowed, suffered from feelings of depression or hopelessness several days a week, and always socially isolated. R79's diagnoses sheet, dated [DATE], indicated the following diagnoses: post-polio syndrome (a condition that causes gradual muscle weakness and atrophy), hypertension (high blood pressure), hemiplegia (paralysis or weakness on one side of the body), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and altered mental status. An Associated…

    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 · D2024-11-14 · 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 interview and document review the facility failed to ensure orders for PRN (as needed) psychotropic medication (mood altering medications) were time limited to 14 days. In addition, the facility failed to ensure provider assessment and documentation of rationale and duration of continuation of a psychotropic PRN medication beyond 14 days occurred for two of six residents (R70 and R40) reviewed for PRN psychotropic medication use. The facility further failed to ensure an indication for use was present for one of six residents (R40) reviewed for psychotropic medication. Findings include: R70 R70's significant change Minimum Data Set (MDS) dated [DATE], indicated R70 was moderately cognitively impaired with the diagnoses of cancer. Section O. indicated R70 was receiving hospice services at the facility. The Current Order Summary dated November 2024, included the order: lorazepam (medication which act on the brain and nerves to produce a calming effect) oral concentrate 2 milligrams per milliliter (mg/ml)…

    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 · Dcited before2024-11-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 2 of 5 residents (R25, R85) were offered, educated and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R25's annual Minimum Data Set (MDS) dated [DATE] indicated R25 was [AGE] years old, was admitted to the facility on [DATE], was severely cognitively impaired, and had the following…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-14 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 1 of 5 residents (R58) reviewed for immunizations. Findings include: Center of Disease Control and Prevention (CDC) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States reviewed 4/4/24, directed the following guidance: For people 12 years or older who are not moderately or severely immunocompromised: -unvaccinated= 1 dose of an updated (2023-2024 Formula) mRNA COVID-19 vaccine OR 2 doses of updated Novavax vaccine. -Previously received 1 or more Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of Original monovalent Novavax vaccine, alone or in combination with any Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of [NAME] vaccine, alone or in…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop a comprehensive baseline care plan within 48 hours after admission to the facility for 1 of 5 residents (R1) whose person-centered care plan instructions were not identified until nine days after admission when she fell and sustained a hip fracture. Findings include: R1's nursing progress note dated 6/27/24 at 9:41 p.m., indicated she arrived at the facility on a stretcher from the hospital. Upon arrival she had behaviors such as hitting staff and trying to stand up. The nurse put her in a wheelchair by the nursing station for close observation to prevent her from falling. She was up most of the night and required the assistance of two staff to toilet her. R1's nursing progress note dated 6/28/24 at 5:48 a.m., indicated she was very confused and resisted care from the staff. R1's admission Minimum Data Set (MDS) dated [DATE], indicated she was admitted to the facility on [DATE]. She had disorganized thoughts during 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 · D2024-03-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to administer blood pressure medication according to physician orders and failed to identify and report the medication errors to the physician for 1 of 1 resident (R1), reviewed for medication management. Findings include: Hypertension (high blood pressure): when the pressure in your blood vessels is too high (140/90 (millimeters of mercury) mmHg or higher). Hypotension (low blood pressure): when blood flows through your blood vessels at lower-than-normal pressures (less than 90/60 mmHg). R1's Prospective Payment System PPS 5-day assessment dated [DATE], identified R1to have intact cognition and had diagnoses of hypertension, cerebral vascular accident (stroke), and congestive heart failure (when your heart can't pump blood hard enough to give your body a normal supply). R1's physician orders dated 1/19/24, identified an order for hydralazine hcl (vasodilator used to treat high blood pressure) to give 50 milligrams (mg) by mouth three times…

    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 · D2023-12-21 · 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 the use of over-the-counter supplements and biologicals was comprehensively assessed for safety and care planned for 1 of 1 resident (R88) reviewed who stored such medications on their bedside table and was consuming them on a daily basis. Findings include: A US Department of Health and Human Services National Institutes of Health (NIH) Probiotics: What You Need To Know article, dated 8/2019, identified probiotics are a live microorganism which could be consumed with potential health benefits. The article outlined probiotics have an extensive history of apparently safe use, however, added, . few studies have looked at the safety of probiotics in detail, so there's a lack of solid information on the frequency and severity of side effects. The article continued and outlined a risk of harmful effects was greater in persons with severe illnesses or compromised immune systems and added, Some probiotic products have been reported 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 · Dcited before2023-12-21 · 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 ensure an allegation of potential abuse or mistreatment was reported to the administrator and State agency (SA) in a timely manner for 1 of 2 residents (R64) whose allegations were reviewed. Findings include: R64's significant change Minimum Data Set (MDS), dated [DATE], identified R64 had moderate cognitive impairment; however, she demonstrated no hallucinations or delusions during the review period. R64's care plan, dated 7/2023, identified R64 had a communication problem due to not speaking English. The care plan outlined, Resident speaks [nationality] and requires interpreter services . knows some basic English words. Further, the care plan outlined R64 was considered vulnerable due to a dependence on institutional services and listed several interventions including, Staff are aware of maltreatment/abuse prevention plan. When suspected maltreatment/abuse occurs, staff are aware to protect and report to supervisor. R64's progress note, dated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · 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 personal hygiene care (i.e., nail care) was completed to promote dignity and reduce the risk of complication (i.e., skin scratch, infection) for 1 of 2 residents (R33) reviewed for activities of daily living (ADLs) and whom was dependent on staff for care. Findings include: R33's admission Minimum Data Set (MDS), dated [DATE], identified R33 had short and long-term memory impairment, had diabetes mellitus, and demonstrated no rejection of care behavior. Further, the MDS outlined R33 required partial/moderate assistance to complete personal hygiene cares. R33's care plan, dated 11/8/23, identified R33 was dependent on staff or family to meet emotional, intellectual and physical needs due to a stroke. The care plan outlined R33 had bowel incontinence along with an ADL self-care deficit, and it listed several interventions to help R33 meet his corresponding needs including, . requires extensive assist from 1 staff 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · 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 ensure wound care was provided according to provider orders to promote healing and reduce the risk of complication (i.e., worsening) for 1 of 1 resident (R61) reviewed for a non-pressure skin condition management. Findings include: R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 was cognitively intact, dependent for transfers, toileting, bathing, and needed minimal assistance to eat and for oral hygiene. R61's admission Record dated 12/20/23, indicated the following diagnoses of iron deficiency anemia, major depressive disorder, generalized muscle weakness, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), dementia, gastro-esophageal reflux (chronic disease that occurs when stomach acids or bile flows back into the tube connecting your mouth and stomach), contracture of multiple sites (a tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints 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 · D2023-12-21 · 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 interview, observation, and document review, the facility failed to ensure that a resident's catheter bag was positioned below bladder level for proper drainage and to prevent the risk of urinary tract infection for 1 of 1 resident (R29) reviewed for urinary catheter care. Findings include: R29's quarterly Minimum Data Set (MDS), dated [DATE] ,indicated R29 had moderate cognitive impairment. R29's care plan, dated 10/11/23, indicated that R29 had an altered pattern of urinary elimination due to a history of bladder cancer and placement of indwelling suprapubic catheter. R29's admission record, dated 6/21/22, indicated diagonoses of chronic kidney disease, cystostomy (surgical creation of an opening in the bladder), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland). R29's provider order, dated 6/22/22, indicated keep leg bag on at all times. During observation on 12/19/23 at 3:01 p.m., R29 was observed lying in bed with the catheter bag also lying in the bed at the level of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-21 · 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 oral hygiene needs, including potential abnormalities and the subsequent need of dental services, were comprehensively assessed or acted upon to reduce the risk of complication (i.e., oral infection, trouble chewing) for 1 of 1 resident (R33) reviewed who had missing teeth. Findings include: R33's admission Minimum Data Set (MDS), dated [DATE], identified R33 had short and long-term memory impairment, had diabetes mellitus, and required partial/moderate assistance to complete personal hygiene cares. Further, the MDS outlined R33 had no identified dental concerns (i.e., loose dentures, abnormal mouth tissue, broken teeth). In addition, R33's Census List, printed 12/21/23, identified R33 was private pay at the care center. R33's Admission/readmission - V5A - V3, dated 10/26/23, identified a section labeled, Oral and Dental, which identified R33 wore no dentures but had abnormal oral mucosa with added text, Very dry mouth. Further,…

    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 · D2023-12-21 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food served to the residents was palatable and at the proper temperature for 2 of 2 residents (R19, R394) who were reviewed for food concerns. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 was cognitively intact, dependent to roll in bed and for toileting, needed substantial assistance with dressing, and set up assistance with oral hygiene and eating. During interview on 12/19/23 at 2:54 p.m., R19 stated the food is always cold and today the hamburger was cold and overcooked. R394's admission Minimum Data Set (MDS), dated [DATE], identified R394 had severe cognitive impairment but demonstrated no delusional thinking or hallucinations. When interviewed on 12/19/23 at 9:35 a.m., R394 stated the food at the care center was terrible and made using poor recipes adding, They [staff] can do much better. R394 was asked on palatability, including serving temperature of the food items, and responded it…

    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 · Dcited before2023-12-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of the 5 residents (R6, R33, and R71) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). In addition, the facility failed to ensure 1 of the 5 residents (R71) was offered and/or provided the influenza vaccination as recommended by the CDC. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after…

    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
  • No harm found · C2026-01-09 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Fiscal Year Quarter 4 2025 - July 1 - September 30) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 116 residents at the facility.Findings include: The CMS PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 dated 1/2/26, indicated the facility had no registered nurse (RN) hours, and lacked licensed nursing coverage for 24 hours per day on the following 25 dates: 8/1, 8/3-8/8, 8/11-8/15, 8/18-8,22, 8/24-8/31. Review of the staff schedules and time sheets indicated the facility had the appropriate licensed 24-hour nursing coverage and RN hours as required. During interview on 1/6/26 at 1:59 p.m., administrator stated she was responsible for submitting the staffing data and was not surprised the report triggered for the missing RN and licensed nursing hours. She stated she attempted to submit the August data 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.

    Administration 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 EBENEZER SENIOR LIVING — 6 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 53.5-0.5 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 5 of 54.2+0.8 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 5 homes this chain runs (chain average 3.5★, 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 / managerTypeRoleSince
DIMICK, MARTHAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
DIRACLES, MARCIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
HARWOOD, TAYLORIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
KILBURG, ELIZABETHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
KIMPTON, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
OLAFSON, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
STICH, LEAHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2023
THORPE, MARYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 07/01/2023
WILLETT, TODDIndividualCORPORATE OFFICERsince 07/01/2023
EBENEZER MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/30/2025
BELL, BRITTANYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
CHEBLI, YASSERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/21/2025
CHRISTOPHER, MACKENZIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/21/2025

CMS files one row per role, so the 24 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$13.5M
Net patient revenuemost recent cost report
-49.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 7%Other / private 45%

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

$581per resident / day
operating cost
$17,661per month
≈ monthly operating cost
$389per 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 245460. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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