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Redeemer Health Care Center

625 West 31st Street, Minneapolis, MN 55408 · Non profit - Corporation · 119 certified beds · (612) 827-2555 Medicare & Medicaid certified

Call the home — (612) 827-2555 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (25) — 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

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.

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
515 W Lake St · (612) 827-7246 · Call to confirm hours
Pharmacy
1221 W Lake St · (612) 824-1036 · Call to confirm hours
Grocery
721 Lake St W · (612) 827-2891 · Call to confirm hours
Park
3101 Bryant Ave S · (612) 370-4907 · Typically dawn to dusk
Place of worship
3100 S Grand Ave

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 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%18.2%15.4%better
Long-stay residents who lose too much weight0.0%4.1%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.5%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.6%2.0%better
Long-stay residents with depressive symptoms1.0%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 injury0.9%4.0%3.3%better
Long-stay residents whose ability to walk worsened4.9%20.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.1%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine96.8%96.1%95.3%typical
Long-stay residents with pressure ulcers3.7%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control12.2%24.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.2%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication2.4%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine91.0%82.7%79.4%better
Short-stay residents rehospitalized after admission19.0%23.5%22.6%better
Short-stay residents with an outpatient ER visit9.7%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days2.211.611.67worse
Long-stay outpatient ER visits per 1,000 resident days1.031.901.80better

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

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

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

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

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

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

57.2% 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 154 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.2%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
71.2%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 71.2% 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 104 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs 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 SNF57.2%CMS range 46.5–66.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.3–14.010.7%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 discharge71.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.6%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 discharge56.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 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 worsened1.6%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 hospitalization7.0%CMS range 4.3–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.76
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.71
Aide hours/ resident / day
4.34
Total nurse hours/ resident / day
0.50
RN hoursweekends
33.8%
Total nursing turnover
42.3%
RN turnover

How full it usually is: this home is certified for 119 beds and averages 110.2 residents a day — about 93% occupied, or roughly 9 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 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 3.93 hrs/resident/day on weekends vs 4.51 on weekdays — 13% thinner on weekends. RN hours go from 0.86 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% 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

7
deficiencies at the latest standard inspection (2025-06-05)
11
at the previous standard inspection (2024-04-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2025-06-05 · tag F0880 — failed to prevent and control infections — pattern
    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 and interview the facility failed to follow infection control standards of practice for cleaning of hard surfaces in the resident room for 1 of 1 residents. In addition, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for 1 of 3 hallways (3rd floor) observed for linen transportation. In addition, the facility had failed to ensure transmission-based precautions (TBP) were assessed for and implemented timely for 1 of 1 residents (R39) reviewed with symptoms of a possible gastrointestinal illness. Findings include: Wheelchair arm rests: According to the Centers for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (2003) the cleaning and disinfection of environmental surfaces is fundamental in reducing their potential contribution to the incidence of healthcare-associated infections. R44's quarterly Minimum Data Set (MDS) dated [DATE] identified R44 with severely impaired…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident and resident guardian's participation in the development of interventions for 1 of 1 resident (R44) reviewed for participation in care planning. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2023, the RAI is used to, assist staff with evaluating goal achievement and revising care plans accordingly by enabling the nurse home to track changes in the resident's status. The RAI, establishes a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative(, resident's physician and interdisciplinary team that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise. The Assessment Reference Date (ARD) refers to the specific endpoint for the observation period in the MDS assessment process and is federally mandated to be completed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interview and document review, the facility failed to ensure the physician was notified of a change in condition for 1 of 1 resident (R32) reviewed for a change of condition. Findings include: R32's admission Minimum Data Set (MDS) dated [DATE], indicated R32 had intact cognition. R32's provider note dated 4/18/25, indicated R32 had a history of a deep vein thrombosis (blood clot, DVT) and a pulmonary embolism (blood clot in the lungs, PE) and remained on Apixaban (blood thinner) twice daily. R32 also had a history of a stroke requiring hospitalization from 12/26/24 to 1/2/25, diabetes, schizoaffective disorder, and cancer. R32's progress note dated 5/29/25 at 7:12 p.m., indicated R32 had an unresponsive episode where the nursing assistant (NA) observed R32 leaning to his left side so licensed practical nurse (LPN)-B was notified. The progress note indicated that LPN-B completed an assessment of R32. The note indicated R32's eyes remained open during the period, and a few seconds into the assessment,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with received medications to promote continuity of care and ensure accurate care planning for 2 of 2 residents (R122 and R311) reviewed for MDS accuracy. Findings include: R122 admission MDS, dated [DATE], indicated R122 was admitted to the care facility on 5/1/25. Section N of the MDS, used to indicated what, if any, high risk medications a resident received in the past seven days, indicated R122 has received insulin injections one time in the past seven days. R122's Physician Order Report, dated 5/1/25 - 6/4/25, lacked evidence R122 was on an insulin injection. The report did indicate R122 received an Ozempic injection once a week on Sundays for a diagnosis of Diabetes Mellitus Type II. However, according to the Resident Assessment Instrument (RAI) Manual for Long-Term Care, Ozempic should not be classified as an insulin injection or a high-risk hypoglycemic medication. Ozempic's classification…

    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 · D2025-06-05 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 2 of 3 residents (R6, R32) reviewed for PAS. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 had intact cognition. R6's medical diagnoses list dated 5/20/25, indicated R6 was diagnosed with schizoaffective disorder with auditory hallucinations. R6's PAS notice dated 5/19/25, indicated a copy of the PAS was included with this notice but the PAS was not final until the lead agency sent a final determination to the nursing home. R6's entire medical record was reviewed and lacked evidence a final determination had been received. R32's admission MDS dated [DATE], indicated R32 had intact cognition. R32's medical diagnoses list dated 4/25/25, indicated R32 was diagnosed with schizoaffective disorder with an acute exacerbation. R32's PAS notice…

    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 before2025-06-05 · 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 oral hygiene was completed to reduce the risk of complication for 1 of 4 residents (R39) reviewed for activities of daily living (ADLs) who were dependent on staff for their care. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had moderately impaired cognition and did not have rejection of care behaviors during the look-back period (LBP). The MDS indicated that R39 required substantial assistance to complete oral hygiene. R39's care plan dated 5/19/25, indicated R39 had full upper dentures, natural teeth on the bottom, with the front teeth missing. The care plan indicated staff were to provide extensive assistance with oral care. R39's Point of Care History dated 5/3/25 to 6/2/25 was reviewed and did not include documentation of oral care. During an interview on 6/2/25 at 3:12 p.m., R39 stated staff were supposed to help her brush her teeth twice a day but had not been doing so. R39…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · 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 a developed skin condition was appropriately and consistently treated to promote healing for 1 of 2 residents (R49) reviewed who had developed dry skin. Findings include: R49's annual Minimum Data Set (MDS), dated [DATE], identified R49 had intact cognition and demonstrated no delusional thinking. Further, the MDS recorded R49 received dialysis and had no current ulcers, wounds or other skin problems (i.e., burns, lesions). R49's care plan, revised 5/19/25, identified R49 required assistance with activities of daily living (ADLs) due to multiple medical conditions including hemiparesis. The care plan outlined R49 was at risk of altered skin integrity due to heart failure and R49 had a history of pressure ulcers. The care plan listed multiple interventions to help R49's skin remain intact including, Moisturize dry skin. On 6/2/25 at 7:09 p.m., R49 was observed lying in bed while in his room. R49 was interviewed and expressed he…

    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 · Ecited before2025-03-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 3 of 4 residents ( R4, R5, R6). In addition, the facility failed to ensure proper personal protective equipment (PPE) was properly utilized for 1 of 4 resident (R4) reviewed for infection control. Findings include: R4 R4's admission Minimum Data Set (MDS) dated [DATE] indicated R4 was cognitively intact, had an indwelling catheter, and was dependent upon staff assistance for transfers. R4's Face Sheet printed 3/25/25, indicated diagnoses included pressure ulcer of sacrum and left thigh, and neuromuscular dysfunction of bladder. R4's care plan dated 2//21/25, indicated an indwelling catheter, and on 3/13/25, indicated enhanced barrier precautions (EBP) (measures intended to prevent the spread of multi-drug resistant organisms ) related to a pressure ulcer. On 3/25/25 at 10:52 a.m., during an observation, there were two signs on R4's door that indicated the following: Enhanced Barrier…

    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 · F2024-04-11 · 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 Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to self administration of medications (SAM) which resulted in a deficiency identified during this survey. Findings include: Review of the CASPER dated 3/28/24, indicated the facility was cited for F755 related to a resident not monitored for medication administration on the survey which exited on 3/2/23. See F554, Based on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 3 of 3 (R66. R6, and R73) residents observed with medications at bedside. Quarter One 2023, QAPI minutes dated 1/1/23, through 3/31/23, were reviewed and indicated under the heading, Survey Results and Audits F755 unattended medication, education was completed, a whole house sweep was completed to check…

    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 · Ecited before2024-04-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed during medication administration for 2 of 4 residents ( R41, R48). The facility also failed to ensure proper hand hygiene was implemented during suprapubic (S/P) catheter cares for 1 of 4 residents (R2), and during the provision of personal cares for 1 of 4 residents (R88) reviewed for infection control. Additionally, the facility failed to ensure proper personal protective equipment (PPE) was utilized for 1 of 1 resident (R266) reviewed for enhanced barrier precautions. Findings Include: Medication Administration R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was cognitively intact. R41's face sheet diagnosis included other sites of candidiasis, urinary tract infection. R48's quarterly MDS dated [DATE], indicated R48 was cognitively intact, and medications included antipsychotics and anticoagulants. R48's care plan updated 4/8/2024, indicated R48 required enhanced barrier…

    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
Show the remaining 15 citations
  • Potential for harm · D2024-04-11 · 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 was completed to allow residents to safely administer their own medications for 3 of 3 (R66. R6, and R73) residents observed with medications at bedside. Findings include: R66's annual Minimum Data Set (MDS) dated [DATE], indicated R66 had modified independence -some difficulty in new situations only- regarding cognitive skill for daily decision making. The MDS further indicated R66 required set up only to extensive assistance for all activities of daily living (ADLs). R66's diagnoses included traumatic brain injury, major depressive disorder, anxiety, opioid dependence, asthma, gastro-esophageal reflux disease (GERD), spinal stenosis, and chronic obstructive pulmonary disease (COPD). R66's care plan indicated R66 had altered respiratory status related to asthma and at risk for nutritional status related to GERD. R66's care plan lacked evidence of self-administration 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 the call light was accessible for 1 of 1 resident (R39) reviewed for accommodation of needs. Findings include: R39's quarterly Minimal Data Set (MDS) dated [DATE], indicated R39 had moderate cognitive impairment, required substantial/maximal assistance with most activities of daily living (ADLs), was dependent on staff for toileting, transfers, and personal hygiene. R39's diagnoses included dementia, renal disease, diabetes, and congestive heart failure. R39's care plan last reviewed 3/27/24, indicated R39 was at risk for falls and instructed staff to make sure call light was within reach. R39's progress note dated 1/14/24, indicated R39 had an unwitnessed fall from bed. R39's falls risk assessment dated [DATE], indicated R39 was at moderate risk for falls and instructed staff to ensure call light was within reach and remind him not to reach for things. During observation and interview on 4/8/24 at 2:32 p.m., R39 was in bed with…

    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 before2024-04-11 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 Resident #83 Based on interview and document review, the facility failed to contact the designated representative and gain consent for medical treatment for 1 of 1 residents (R83) reviewed for notification of change. Findings include: R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated he continuously had altered levels of consciousness and was rarely or never understood. MDS indicated R83's diagnoses included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and dementia (a loss of memory, language, problem-solving and other thinking abilities). MDS indicated R83 was dependent on staff for assistance with activities of daily living (ADL), mobility, and transfers. R83's medication administration record dated 12/2023, indicated oseltamivir (Tamiflu) 75 milligrams (mg), an antiviral medication used to prevent or treat influenza, was administered from 12/8/23 through 12/21/23. R83's care plan dated 4/14/22, indicated he was at risk for decline and identified…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 draw privacy curtains or close the residents door during personal cares, making a resident feel their personal privacy was not being protected for 1 of 1 resident (R1) reviewed for personal privacy and confidentiality. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], included R1 was cognitively intact, dependent on staff for transfers and toileting, and required moderate assistance with upper body dressing and maximal assistance for lower body dressing. R1 had diagnoses of quadriplegia, anxiety, and neurogenic bladder. R1's care plan dated 4/3/23, included R1 required extensive assist of two staff for bed mobility, 1-2 staff for dressing and toileting, and assist of two staff for transfers using a full body mechanical lift. During interview on 4/8/24 at 2:52 p.m., R1 stated they had a roommate and did not get enough privacy. They stated recently they were receiving personal cares and the nursing assistant (NA)…

    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 · D2024-04-11 · 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 interview and document review, the facility failed to ensure a baseline care plan was reviewed and provided timely to ensure knowledge of care and promote person-centered care planning for 1 of 2 residents (R74) reviewed for care planning. Findings include: R74's face sheet undated, indicated R74 admitted to the facility 1/12/24, was readmitted to the hospital on [DATE], and readmitted to the facility on [DATE], was readmitted to the hospital on [DATE] and readmitted to the facility on [DATE]. R74's admission cognition assessment dated [DATE], indicated R74 was cognitively intact. R74's diagnoses list indicated R74's diagnoses included end stage renal disease, diabetes mellitus, dependence on renal dialysis, depression, long term use of insulin, nicotine dependence and bipolar disorder. R74's baseline care plan initiated 1/18/24, included pain, psychotropic medications, falls, skin, medical conditions, dialysis, and discharge plan. During interview on 4/9/24 at 8:54 a.m., R74 indicated she was not…

    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 before2024-04-11 · 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

    Based on observation, interview, and document review, the facility failed to accurately assess and monitor multiple non-healing and bleeding skin lesion, lacerations, and scabs for 1 of 1 resident (R40) reviewed for non-pressure related skin conditions. Findings include: R40's significant change Minimum Data Set (MDS)-dated 3/6/24, indicated they were cognitively intact, had diagnoses of heart failure, peripheral vascular disease, kidney failure, diabetes, and lower limb amputation. R40 was dependent on staff for showers, dressing, personal hygiene, and transfers, and was at risk for pressure ulcers but had no unhealed pressure ulcers or arterial or venous ulcers. R40's care plan dated 1/23/24, indicated R40 had an alteration in skin integrity, and instructed licensed staff to complete visual body observation weekly, implement appropriate interventions for any areas of concern, and notify provider and family of any new areas of concern. In addition, nursing assistants were directed to observe skin daily during cares and notify nurse promptly of any areas of concern. The care plan…

    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 · D2024-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assure properly operational pressure-reducing air mattress were in place as intervention to reduce pressure ulcers for 2 of 3 residents (R39 and R87) reviewed for pressure ulcers. Findings include: R39 R39's quarterly Minimal Data Set (MDS) dated [DATE], indicated R39 had moderate cognitive impairment, required substantial/maximal assistance with most activities of daily living (ADLs), and was dependent on staff for toileting, transfers, and personal hygiene. The MDS indicated R39 was at risk for developing pressure ulcers and required pressure reducing device for bed. R39's diagnoses included dementia, renal disease, diabetes, and congestive heart failure. R39's pressure ulcer/injury care area assessment (CAA) dated 9/29/23, indicated R39 was at risk for developing pressure ulcers due to immobility and incontinence and required a special mattress to reduce or relieve pressure. R39's wound assessment dated [DATE], indicated, Patient has…

    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 · D2024-04-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 1 residents (R40) reviewed for dialysis. Findings include: R40's significant change Minimum Data Set (MDS) dated [DATE], indicated the were cognitively intact, and had diagnoses of kidney failure, high blood pressure, diabetes, heart failure, and peripheral vascular disease. The MDS indicate R40 did not receive dialysis treatments while in the facility. R40's care plan dated 1/6/24, indicated R40 required hemodialysis related to end-stage kidney disease, had a shunt in their left arm for vascular access, and lacked pre- and post-dialysis instructions for monitoring of access site, shunt bruit and thrill, and vital signs. R40's Referral Forms and progress notes dated 3/4, 3/7, 3/11, 3/15, 3/18, 3/20, 3/27, 4/1, 4/3 and 4/8/24, indicated they had dialysis on those dates. No additional forms were included in the medical record. R40's Physician Order Report dated 4/11/24,…

    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 · D2024-04-11 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 medically related social services and/or obtain mental health counseling for 1 of 1 resident (R87) diagnosed with major depressive disorder and inappropriate tendencies towards staff reviewed for behavioral services. Findings include: R87's quarterly MDS dated [DATE], indicated R87 had moderate cognitive impairment, and required partial/moderate to substantial/maximal assistance with most activities of daily living (ADLs). The MDS indicated R87 received antidepressant medication. R87's diagnoses included dementia, depression, and had a history of homicidal ideations. R87's care plan (CP) dated 3/13/24, identified R87 was at risk for mood and behavioral disturbance r/t (related to) diagnosis of depression and history of inappropriate sexual behavior. The CP further identified R87 at risk for psychosocial well-being with intervention, Refer to psychologist/psychiatrist as appropriate. R87's PHQ-9 (patient health questionnaire for depressive…

    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 · E2024-03-08 · tag F0742 — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 comprehensive trauma assessments were completed to ensure appropriate treatment and services for 6 of 6 residents (R1, R2, R3, R4, R5 and R6) who had a history of traumatic events. Findings include: Facility matrix for providers identified one resident triggered for post traumatic stress disorder (PTSD)/Trauma in the facility. R1's face sheet identified R1 had diagnoses that included cerebral palsy, mood disorder due to known physiological condition and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and did not display behaviors. R1's abuse assessment observation dated 4/26/23, identified R1 had a history of being abused by others. Stepfather was an alcoholic and he was in the service so he would hurt her because she was from Yugoslavia. Although R1's record identified R1 had a history of past abuse a comprehensive trauma assessment that would identify potential triggers and interventions…

    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 · Fcited before2023-03-02 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to implement a comprehensive infection control program to include tracking of infections, illness with timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified to reduce the risk of spreading infections to other residents. This had the potential to effect all 111 residents residing in the facility. Findings include: During an interview on 3/2/23, at 12:11 p.m. the facility infection preventionist (IP) stated they had previously tracked infections and antibiotics in an ongoing monthly log, but in December of 2022, the facility decided to change the monthly tracking to quarterly. The IP stated they were unable to obtain an infection and antibiotic tracking logs because they had not completed them since December. IP stated that in the facility daily meeting, a report was conducted for residents on antibiotics so they can be discussed. The IP was unable to provide log of surveillance for infections and communicable diseases. During an interview on 3/2/23, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-02 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to implement a comprehensive antibiotic stewardship program with established monitoring to help reduce unnecessary antibiotic use, reduce potential drug resistance, ensure appropriate antibiotics were utilized to prevent antibiotic resistance and help prevent the spread of infectious diseases. This deficient practice had the potential to affect all 111 residents residing at the facility. Findings include: During interview on 3/2/23, at 12:11 p.m. the facility infection preventionist (IP) stated they had previously tracked infections and antibiotics in an ongoing monthly log, but in December of 2022, the facility decided to change the monthly tracking to quarterly. The IP stated they were unable to obtain an infection and antibiotic tracking log because they were not completed since December, 2022. IP stated that in the facility daily meeting, a report was conducted for residents on antibiotics so they can be discussed. During interview on 3/2/23, at 1:28 p.m. the director of nursing (DON) stated the way infections 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide routine personal grooming and cleanliness for 1 of 2 residents (R31) reviewed for activities of daily living (ADLs) who were dependant on staff for their care. Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 had severe cognitive impairment, had no physical or verbal behaviors, and no refusal of cares. R31 required extensive assistance with personal hygiene and bathing. R31's diagnoses included unspecified severe protein-calorie malnutrition-hospice (poor food intake), diabetes mellitus with diabetic neuropathy (pain and numbness in feet), and bipolar disorder (mood swings). R31's care plan updated 2/3/2023, indicated, R31 was at risk for alteration in skin integrity. Approach indicated licensed staff were to complete a visual body observation weekly. Implement appropriate interventions for any areas of concern and notify provider and family of near areas of concern. Nursing assistants (NA) 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 · Dcited before2023-03-02 · 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 and manage resident symptoms at a level consistent with the current professional standards of practice for 1 of 1 residents evaluated for loose stools. Findings include: R34's Minimum Data Set (MDS) dated [DATE], indicated R34 was cognitively intact, totally dependent on staff for toileting during the review period, incontinent of bowel, and was not on a bowel toileting program. The MDS further indicated R34 had a diagnosis of constipation. During interview on 2/27/23, at 1:12 p.m. R34 stated loose stools had been a recurrent issue since admission, happening several times per week. R34 was unaware of any bowel management program. During interview on 3/1/23, at 8:47 a.m. R34 stated staff were informed about the concern with loose stools, and staff did nothing about the loose stools. Staff provided incontinent care after each episode of loose stools. Bowel movement records obtained 3/3/23 dated 12/1/22 to 3/2/23 indicated staff document R34 had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · 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 ensure prescribed medication was not left unattended in resident room, for 1 of 1 resident, (R89), who was observed to store narcotic medication in room, and not monitored for medication administration. Findings include: R89's quarterly Minimum Data Set (MDS) dated [DATE], indicated R89 was cognitively intact, had no physical or verbal behaviors, no refusal of cares or no mood distress. The MDS further indicated R89 required extensive assistance with dressing, transferring from bed to chair, and personal hygiene with assistance of one staff and had pain. R89's care plan revised on dated 3/26/22, indicated R89 had a history of pain related to a compression fracture. Interventions included pain medications as ordered. R89's physician order dated 2/6/23, included the following medication: Oxycodone, one 5 mg tablet given orally three times a day at 8:00 a.m., 1:00 p.m., and 7:00 p.m. During interview on 2/28/23, at 2:56 p.m., RN-A stated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CASSIA — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.4+0.6 vs chain
Health inspection 3 of 53.7-0.7 vs chain
Staffing 5 of 54.8+0.2 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 15 homes this chain runs (chain average 4.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ELIM CARE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/04/1993
COLGAN, DANNYIndividualW-2 MANAGING EMPLOYEEsince 01/25/2012
LEFF, WILLIAMIndividualCORPORATE DIRECTORsince 05/18/2000
NYE, GERALDIndividualCORPORATE DIRECTORsince 06/13/2019
PETERSON, ROLANDIndividualCORPORATE DIRECTORsince 11/14/2013
TANGEDAHL, GUYIndividualCORPORATE DIRECTORsince 05/17/2012
DAHL, ROBERTIndividualCORPORATE OFFICERsince 01/04/1993
KERN, MATTHEWIndividualCORPORATE OFFICERsince 02/28/2019
YOUNGQUIST, KATHRYNIndividualCORPORATE OFFICERsince 01/04/1993
CASSIAOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020

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

Follow the money — this home’s finances

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

$15.5M
Net patient revenuemost recent cost report
+1.6%
Operating marginrevenue minus expenses
$2.2M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 5%Other / private 28%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$375per resident / day
operating cost
$11,387per month
≈ monthly operating cost
$381per 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 245520. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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