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Victory Health And Rehabilitation Center

512 49th Avenue North, Minneapolis, MN 55430 · For profit - Limited Liability company · 79 certified beds · (612) 529-7747 Medicare & Medicaid certified

Call the home — (612) 529-7747 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4209 Webber Pkwy · (763) 581-5750 · Call to confirm hours
Pharmacy
5255 E River Rd Ste 204 · (800) 680-4487 · Call to confirm hours
Grocery
4539 Lyndale Ave N · (612) 522-9222 · Call to confirm hours
Park
4900 Mississippi Ct · (763) 694-7693 · Typically dawn to dusk
Place of worship
4656 Colfax Ave N · (612) 521-3575

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 3 of 5
Long-stay residentspeople who live here 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 2025-03 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
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 increased22.6%18.2%15.4%worse
Long-stay residents who lose too much weight0.9%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.4%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.3%2.6%2.0%better
Long-stay residents with depressive symptoms6.9%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 injury4.8%4.0%3.3%worse
Long-stay residents whose ability to walk worsened19.4%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.0%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%96.1%95.3%typical
Long-stay residents with pressure ulcers6.0%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control23.1%24.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.1%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication6.1%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine80.0%82.7%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.221.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.461.901.80better

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.

29.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

29.1%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF29.1%CMS range 18.3–45.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.3–14.310.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.38
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.10
Total nurse hours/ resident / day
0.21
RN hoursweekends
40.7%
Total nursing turnover
77.8%
RN turnover

How full it usually is: this home is certified for 79 beds and averages 70.3 residents a day — about 89% 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.50 hrs/resident/day on weekends vs 3.33 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.44 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-01-15)
7
at the previous standard inspection (2024-12-19)

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 · D2026-06-02 · 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

    Based on interview and document review, the facility failed to perform complete and thorough investigations of allegations of abuse for 3 of 3 residents (R1, R2, R3) who were involved in resident-to-resident altercations. Findings include:A Nursing Home Incident Report (NHIR) dated 5/26/26 at 8:20 p.m., indicated at approximately 6:25 p.m., when R2 and R3 were both in the dining room, R2 struck R3 in the chest and face. Facility initiated 15-minute safety checks. The incident was witnessed by activity staff. A NHIR dated 5/26/26 at 10:30 p.m., indicated at 7:39 p.m., R2 and R1 were involved in a physical altercation in which R2 hit and scratched R1. Staff intervened and separated the residents, and staff performed monitoring and safety checks. Review of the investigative files on 6/1/26 of each of the two incidents revealed the investigations did not include interviews with other residents to ensure the other residents did not also have allegations of abuse by R2. During an interview on 6/2/26 at 12:09 p.m., the director of nursing (DON) stated during an investigation for abuse,…

    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 before2026-06-02 · 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 ensure a safe environment was maintained and monitoring was implemented as indicated in the medical record for 2 of 3 residents (R1, R3), and as ordered for 1 of 3 residents (R2) after resident-to-resident altercations.Additionally, the facility failed to ensure ongoing assessment and monitoring for 2 of 2 residents (R1, R3) after R1 was hit and scratched by R2, and R3 was hit in the torso and slapped by R2, which had the potential to result in unmonitored decline for R1 and R3.Findings include:A Nursing Home Incident Report (NHIR) dated 5/26/26 at 8:20 p.m., indicated at approximately 6:25 p.m., when R2 and R3 were both in the dining room, R2 struck R3 in the chest and face. Facility initiated 15-minute checks. The incident was witnessed by activity staff. A NHIR dated 5/26/26 at 10:30 p.m., indicated at 7:39 p.m., R2 and R1 were involved in a physical altercation in which R2 hit (did not indicate where ) and scratched R1. Staff intervened 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 · Fcited before2026-01-15 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F880Based on observation, interview and document review the facility failed to store soiled linens, and transport linens to prevent the spread of infection. This had the potential to affect all 65 residents whose personal laundry was done at facility.Findings include: An observation on 1/14/26 at 8:16 a.m., laundry assistant (LA) carried an arm load of clean laundry on hangers, draped over arm, up against scrubs and brought into an unidentified resident's room.An observation on 1/14/26 at 8:19 a.m., on the outside laundry room door, a yellow sign stated: NURSING STAFF 1. Soiled linen MUST be bagged and taken to laundry room. Placed in proper container/bin, at the end of every shift. 2. Outgoing laundry must be put in blue bag, placed in proper bin in soiled room [ROOM NUMBER]. DO NOT put any soiled linens on the floor. Inside of the laundry room, there were large containers for facility laundry, empty blue fabric bags on a table, and two filled blue bags sitting on the floor in front of containers. There were…

    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 · E2026-01-15 · tag F0553 — failed to let residents help plan their care — pattern
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to allow active resident and resident representative participation in the development and review of care plans for 4 of 4 residents, (R3, R25, R30, R14) reviewed for care planning and coordination of services while residing at the facility. Findings include: R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, no adverse behaviors, and was dependent on staff for wheelchair mobility. R3's medical record identified the most recent care conference was held on 8/20/25, and no additional care conferences were held. R3 had an additional quarterly MDS completed on 11/9/25, There was no indication in the progress notes or medical record of any care conference held at the time of this assessment. During an interview on 1/13/26 at 8:22 a.m., R3's representative (RR)-A stated he was not invited to a recent care conference, and he had concerns about communication with the facility. R25 R25's quarterly MDS dated [DATE],…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-15 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 obtain and document an informed consent including explanation of risk and benefits, for 1 of 1 newly admitted resident (R80) reviewed for use of psychotropic medications.Findings include:R80's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no adverse behaviors and moderately severe depression. R80 was dependent on staff for bed mobility and had a diagnosis of complete paraplegia (complete loss of sensation and movement from the chest down). Medications included antianxiety and antidepressant.R80's Medication Administration Record (MAR) dated 12/30/25 through 12/31/25, identified alprazolam (antianxiety medication) 1 milligram (mg) by mouth as needed (PRN) for anxiety was given twice on 12/31/25, and documented as E which meant effective.R80's MAR dated 1/1/26 through 1/15/26, identified PRN alprazolam was given twice on 1/1/26, twice on 1/4/26, once on 1/5/26, twice on 1/6/25, once on 1/7/26, once on 1/8/26 and once 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 before2026-01-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow standards of practice to provide resident education and update the provider for 1 of 1 resident (R33) who routinely refused their diuretic medication.Findings include:R33's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, no adverse behaviors, was independent with meals and hygiene and had a diagnosis of chronic systolic (congestive) heart failure (CHF).R33's care plan dated 11/8/25, identified he was on a diuretic medication related to CHF. Interventions included administer diuretic medications as ordered by physician and monitor/document/report adverse reactions to diuretic therapy.R33's orders identified start date of 2/20/25, for bumetanide 1 milligram (mg) tablet, give two tablets two times a day related to CHF.R33's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25, identified bumetanide was refused 45 out of 60 opportunities. The MAR dated 12/1/25 through 12/31/25, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · 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 communicate with a resident's emergency family contact when they were hospitalized and subsequently discharged from the facility for 1 of 2 residents (R1) reviewed for discharge process.Findings include:R1's electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and discharged on 9/13/25.R1's progress note, dated 9/13/25, indicated R1 was not redirectable and walking towards traffic and sent to the emergency department (ED) due to safety concern to self.R1's EMR lacked any evidence the facility communicated with R1's family about any potential safety concerns, his hospitalization, and discharge from the facility. During an interview on 11/10/25 at 9:50 a.m., R1's emergency contact and family member (FM)-A stated she was not informed of any incidents regarding R1 walking outside in traffic and was never informed he was hospitalized . FM-A stated she arrived at the facility on a Wednesday or Thursday to bring R1 some…

    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 · D2025-12-03 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 written notice of transfer and bed hold was given to a resident and/or their family upon hospitalization for 1 of 2 residents (R1) reviewed for discharge. Findings include:R1's electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and discharged on 9/13/25.R1's progress note, dated 9/13/25, indicated R1 was not redirectable and walking towards traffic and sent to the emergency department (ED) due to safety concern to self.R1's EMR lacked any evidence R1 and/or family had received a written notice of transfer and information on the facility's bed hold policy when R1 was hospitalized on [DATE].During an interview on 11/10/25 at 9:50 a.m., R1's emergency contact and family member (FM)-A stated she was not informed when R1 was sent to the hospital, did not received a written notice of transfer or any information on the facility bed hold policy.During an interview on 11/10/25 at 11:12 a.m., the facility social worker…

    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 · D2025-12-02 · 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 assessment was completed for 1 of 1 resident (R2) observed with medication at their bedside.Findings include:R2's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses included morbid obesity and asthma.R2's self-administration of medications assessment dated [DATE] indicated R2 did not want to self-administer any medicationsR2's current provider orders on 10/21/25 included albuterol sulfate inhalation solution. 1 puff inhale orally every 4 hours as needed for shortness of breath due to asthma. R2's care plan dated 9/8/25 did not identify R2 did not identify a focus and/or interventions for self-administration of medication. During an observation and interview on 10/21/25 at 12:41 p.m., an inhaler was observed in a bowl on R2's bedside table. R2 stated he kept the inhaler next to his bed so he could use it as needed a couple of times a week. R2 did not tell…

    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 before2025-12-02 · 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

    Based on observation, interview and document review, the facility failed to accommodate resident needs by ensuring call light buttons were within reach for 1 of 2 (R3) residents reviewed for call light usage.Findings include:R3 quarterly minimum date set (MDS) date 7/31/25 indicated severe cognitive impairment with diagnoses included schizoaffective disorder, bipolar type and catatonic schizophrenia.R3's care plan dated 9/8/25 instructed to be sure resident's call light is within reach and encourage resident to use it.During an observation and interview on 10/20/2025 at 2:41 p.m., R3 was lying in her bed. A cord was coming out of the wall near the head of the bed, but no call button was observed. R3 stated she did not have a call button. If she needed help, she would wave at staff as they walked by or would say help me. During an observation and interview on 10/20/2025 at 2:51 p.m. licensed practical nurse (LPN)-A confirmed R3's call light was lying on the floor under her bed. LPN-A stated the call light should have been attached to R3's bed where she could reach it. Resident's call…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2025-12-02 · 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

    Based on interview and document review the facility failed to monitor temperature and intravenous access (IV) site for 1 of 1 resident (R3) following electroconvulsive therapy (ECT).Findings include:ECT is a procedure done under general anesthesia. During this procedure, small electric currents pass through the brain, intentionally causing a brief seizure. ECT seems to change brain chemistry, and these changes can quickly improve symptoms of certain mental health conditions. Electroconvulsive therapy (ECT) - Mayo Clinic R3 quarterly minimum date set (MDS) date 7/31/25 indicated severe cognitive impairment with diagnoses included schizoaffective disorder, bipolar type, and catatonic schizophrenia.R3's care plan dated 9/8/25 indicated R3 had ECT treatment 2 times a week on Tuesday and Thursday. Following treatment R3 should be monitored for extreme headache, nausea, vomiting, confusion, temperature greater than 100.5, redness, swelling, and drainage or pain at the IV site lasting more than 24 hours.R3's ECT discharge orders and information dated 10/2/25, 10/7/25, 10/9/25, 10/14/25,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-08 · 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 for 2 of 2 residents (R1, R2) who were involved in a resident-to-resident physical altercation, was reported immediately but no later than 2 hours to the State Agency (SA).Findings include:A Facility Reported Incident (FRI) submitted to the SA indicated on 8/29/25 at approximately 11:00 p.m. a verbal altercation between R1 and R2 occurred and R1 allegedly struck R2 in the face. The report was submitted to the SA on 9/3/25 at 11:45 a.m.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had no behaviors. R2's modification of significant change MDS dated [DATE], indicated R2 was cognitively intact, and had verbal behaviors 1-3 days in the 7-day look-back period.R2's hospital Discharge summary dated , 8/30/25 indicated a diagnosis of a dislocation of left side of jaw that was reduced, able to open but not close fully, contusion right chest wall.Prescribed oxycodone 5 mg, 1…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure medications were stored and secured safely in 1 of 1 medication carts observed. Findings include:During an observation on 9/5/25 from 1:07 p.m. to 1:39 p.m., the medication cart outside the dining room on the [NAME] Hall was unlocked and unattended. During that time, thirteen staff and eleven residents walked by the unlocked cart. One of the residents touched items on top of the cart. During an observation and interview on 9/5/25 at 1:39 p.m., licensed practical nurse (LPN)-A returned to the medication cart, and stated she had been away to another area for about 30 minutes. LPN-A stated the cart was supposed to be locked to prevent others from accessing the medications in the cart. During an interview on 9/5/25 at 3:40 p.m., LPN-B stated when she leaves the medication cart, she is supposed to lock it. During interview on 9/8/25 at 10:37 a.m., the director of nursing stated it was critical for nurses to lock medication carts before they walk away from the cart to prevent access from unauthorized staff,…

    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 · D2024-12-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R164) reviewed for dignity. Findings include: R164's admission Minimum Data Set (MDS) dated [DATE], indicated R164 had severe cognitive impairment, upper and lower extremity impairment of one side of the body, required substantial/maximal assistance with meals and a mechanically altered diet. R164's diagnoses included stroke, aphasia (condition limiting speech and understanding), dysphagia (condition affecting ability to swallow), and right-sided hemiplegia (paralysis affecting one side of the body). R164's care plan dated 12/5/24, indicated R164 had activities of daily living (ADL) self-care performance deficit related to stroke and was able to eat independent after set up by staff using a divided plate. R164's physician order dated 12/4/24, indicated, Resident is to be up in w/c for meals. Aides are to feed resident and check mouth for pocketing food. During observation 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 before2024-12-19 · 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 a call light was accessible for 1 of 3 residents (R164) reviewed for call lights. Findings include: R164's admission Minimum Data Set (MDS) dated [DATE], indicated R164 had severe cognitive impairment, upper and lower extremity impairment of one side of the body, required substantial/maximal assistance with most activities of daily living (ADL). R164's diagnoses included stroke, aphasia (condition limiting speech and understanding), and right-sided hemiplegia (paralysis affecting one side of the body). R164's care plan dated 12/5/24, indicated R164 was at risk for falls r/t (related to) CVA (cerebral vascular accident) affecting right dominant side of body. The care plan instructed staff to ensure resident's call light was within reach and to encourage him to use it. During observation on 12/16/24 at 1:20 p.m., R164 door was open and visible from the hallway. R164 was awake in bed with call light inside the top drawer of his…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure food preferences of the resident were honored and implemented for 1 of 2 residents (R24) reviewed for choices. Findings include: R24's Medical Diagnosis form indicated the following diagnoses: multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), type II diabetes mellitus with hyperglycemia (high blood sugar), major depressive disorder and adjustment disorder. R24's Clinical Physician orders form indicated a diabetic diet encourage fluids, regular texture, and thin liquids consistency. R24's dietary slip on the breakfast tray on 12/18/24 indicated Diet- CCHO - Regular (Consistent Carbohydrate Diet), Liquids - Thin . Orange juice, grits and sausage link were crossed out. Observation on 12/18/24 at 8:00 a.m., the staff brought R24's breakfast tray, which consisted of 8 oz orange juice, 8 oz of milk, a bowl of frosted flakes, a piece of toast and an omelet. Interview on 12/18/24 at 8:05 a.m., R24 indicated that R24 had requested no orange juice.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a resident was provided the appropriate therapeutic diet and meal supervision for 1 of 1 resident (R164) reviewed for nutrition. Further, the facility failed to ensure a resident was transferred from bed to wheelchair in a manner assessed safe for 1 of 2 residents (R164) observed during transfers. Findings include: R164's admission Minimum Data Set (MDS) dated [DATE], indicated R164 had severe cognitive impairment, upper and lower extremity impairment of one side of the body, required substantial/maximal assistance with most activities of daily living (ADL) including eating and transfers, and required a mechanically altered diet. R164's diagnoses included stroke, aphasia (condition limiting speech and understanding), dysphagia (condition affecting ability to swallow), and right-sided hemiplegia (paralysis affecting one side of the body). R164's care plan dated 12/5/24, indicated R165 had an ADL self-care performance deficit…

    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 · D2024-12-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 2 residents (R1). The facility failed to ensure that the resident was set up with assistance for meals and failed to provide a nutritional supplement that was needed to implement interventions to prevent further weight lost for 1 of 2 residents (R1) who had a significant unplanned weight loss. Further finding includes: R1's admission record indicated, R1 was admitted on [DATE] with the following diagnosis: Vascular Dementia with sever agitation, Cardiomyopathy (enlargement of the heart), Dysphagia (difficulty swallowing), Major Depressive Disorder, Delusional Disorders (disorganized thoughts and actions), Psychosis, Crohn's Disease, Type 2 Diabetes Mellitius (controlled), Anxiety disorder, History of Transient ischemic attacks (TIA's), Atherosclerosis heart disease, Hypertension, Insomnia, and adult failure to thrive. R1's quarterly Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · 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 record review the facility failed to ensure a PRN (as needed) psychotropic medication order included an end date for 1 of 1 residents (R16) reviewed for PRN psychotropic medications. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had moderate cognitive impairment and diagnoses of lung cancer and depression. Furthermore, R14's MDS indicated R14 received hospice care and had received psychotropic medications for anxiety. R14's provider order dated 12/13/24, indicated R14 required Lorazepam concentrate (psychotropic medication for anxiety) 0.25milliliters (ml) every 4 hours PRN for anxiety. The order did not include a stop date. R14's Medication administration record (MAR) dated 12/2024 showed R14 had received Lorazepam on 12/13/24. When interviewed on 12/18/24 at 11:16 a.m., licensed practical nurse (LPN)-C verified R14's Lorazepam order did not include a stop date. LPN-C stated the order should be used for 14 days unless the provider gave a reason.…

    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 · D2024-12-19 · tag F0811 — isolated
    Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents with difficulty swallowing were assisted with meals only by qualified individuals. Findings include: R164's admission Minimum Data Set (MDS) dated [DATE], indicated R164 had severe cognitive impairment, upper and lower extremity impairment of one side of the body, required substantial/maximal assistance with meals and a mechanically altered diet. R146 had three days of speech therapy and four days of occupational therapy in the seven day lookback period. R164's diagnoses included stroke, aphasia (condition limiting speech and understanding), dysphagia (condition affecting ability to swallow), and right-sided hemiplegia (paralysis affecting one side of the body). R164's December Care Task sheet indicated, ADL [activities of daily living]-Eating: dependent of 1 watch for pocketing food. R164's physician order dated 12/4/24, indicated, Resident is to be up in w/c for meals. Aides are to feed resident and check mouth 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 low-temperature chemical sanitizing commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. This had potential to affect all 62 residents within the facility, staff, and visitors who consumed food from the main production kitchen. Findings include: During observation and interview on 6/11/24 at 12:04 p.m., dietary manager (DM) stated staff used chlorine test strips to determine if the chemical sanitizer concentration was adequate for sanitization by dipping the strip into the bottom reservoir of the dish machine and comparing the color to the key on the test strip label container. They indicated it must read between 100-200 parts per million (ppm). DM demonstrated the process, and the solution tested at 100 ppm. DM loaded a tray of pans, placed it in the dish machine, and closed the door to start the unit. The water temperature gauge read 113 degrees Fahrenheit (°F). DM…

    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 · Ecited before2024-06-13 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 record review the facility failed to ensure coordination of scheduled and/or follow up appointments was completed for 2 of 3 residents (R38, R47) who required services from outside medical providers, and failed to ensure monitoring for edema (condition where fluid builds up in the body) for 1 of 1 residents (R19) reviewed for edema. Furthermore, the facility failed to ensure medications were administered following standard practice for 1 of 1 resident (R58) reviewed for tube feeding. Findings include: coordination of appointments R38's significant change Minimum Data Set (MDS) dated [DATE], indicated R38 had cognitive impairment and diagnoses of glioblastoma (aggressive type of brain cancer) and schizophrenia. R38's clinical appointment list dated 6/12/24, indicated R38 did not show up/had rescheduled appointments for 12/1/23, 12/15/23, 1/3/24, and 1/16/24. R38's neurosurgery clinic call documentation note dated 11/28/23 at 9:01 a.m., indicated the clinic called the facility…

    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 · D2024-06-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to include individualized approaches for care, including non-pharmacological interventions to aid in the management of behavior, in the comprehensive care plan for 2 of 5 residents (R1, R6) reviewed for unnecessary medications. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], included R1 was moderately cognitively impaired, had diagnoses of dementia, depression, and psychotic disorder (other than schizophrenia). R1 took antidepressant and antipsychotic medications on a routine basis. R1's Mood State Care Area Assessment (CAA) was not triggered. R1's Psychotropic Drug Use Care Area Assessment (CAA) indicated R1 took antipsychotic medications, was at risk for adverse reactions from the medications, and had no noted side effects. R1's Order Summary Report dated 6/5/24, included: *Aripiprazole tablet 5 milligrams (mg) one time per day for psychosis starting 6/1/24. *Sertraline HCl (hydrochloride) tablet, 150 mg one…

    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 before2024-06-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify individualized approaches for care, including non-pharmacological interventions to aid in the management of mood and behavior, for 2 of 5 residents (R1, R27) reviewed for unnecessary medications. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], included R1 was moderately cognitively impaired, had diagnoses of dementia, depression, and psychotic disorder (other than schizophrenia). R1 took antidepressant and antipsychotic medications on a routine basis. R1's Mood State Care Area Assessment (CAA) was not triggered. R1's Psychotropic Drug Use Care Area Assessment (CAA) indicated R1 took antipsychotic medications, was at risk for adverse reactions from the medications, and had no noted side effects. R1's Order Summary Report dated 6/5/24, included: *Aripiprazole tablet 5 milligrams (mg) one time per day for psychosis starting 6/1/24. *Sertraline HCl (hydrochloride) tablet, 150 mg one time per day 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure appropriate hand hygiene practices were performed following personal cares and catheter care for 1 of 1 resident (R58) observed during cares. In addition the facility failed to ensure enhanced barrier precautions (EBP) were utilized for 1 of 1 resident (R56) reviewed who received dialysis. Findings include: R58's admission Minimum Data Set (MDS) dated [DATE], identified R58 had moderately impaired cognition and required physical assist from another person for activities of daily living (ADLs) including toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Diagnoses included stroke, hemiplegia (one-sided paralysis), and cataracts. R58 had an indwelling catheter. R58 care plan dated 5/29/24 noted R58 was on enhanced barrier precautions related to an indwelling catheter and tube feeding. During observation on 6/11/24 at 9:38 a.m., nursing assistants (NA)-B and NA-C we observed wearing isolation gowns and gloves during cares.…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
SHERMAN, ISRAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2019
DE COSTA, DENNISIndividualW-2 MANAGING EMPLOYEEsince 09/26/2019

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.

$6.9M
Net patient revenuemost recent cost report
-17.1%
Operating marginrevenue minus expenses
$620K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 8%Other / private 23%

This home reported $620K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$376per resident / day
operating cost
$11,424per month
≈ monthly operating cost
$321per 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 245544. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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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