St Clare Living Community Of Mora
110 North 7th Street, Mora, MN 55051 · Non profit - Corporation · 65 certified beds · (320) 679-1411 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $41,955 in federal fines (most recent 2023-11-06)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 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 fell from 3 to 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.3% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.7% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.5% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.7% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.2% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.9% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.3% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.4% | 14.8% | 12.0% | worse |
* 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.
65.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.5% 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 80 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.7%CMS range 54.5–73.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.0–15.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 62.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.8% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 84.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | 88.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.6–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.48 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 65 beds and averages 47.3 residents a day — about 73% occupied, or roughly 18 beds typically open. It usually has some room. 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 4.36 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.22 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 23% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 record review the facility failed to ensure the code alert system (a wander management system to protect residents from elopement) was functioning properly, failed to follow manufacture recommendation for weekly testing, and failed to follow manufacture recommendations for inspection. This resulted in an immediate Jeopardy situation for two residents (R19, R12) who were at risk for elopement and were able to get through the main doors, due to failure of the doors to lock as required per the code alert system. In addition, the facility failed to adequately assess and develop care plans for residents identified at risk for elopement and wandering for 14 of 14 residents (R19, R12, R3, R4, R13, R17, R18, R22, R25, R28, R32, R34, R37, R46) who were assigned code alert devices and had the potential for elopement.The IJ began on [DATE] at 2:18 p.m., when R12 was able to exit the building due to code alert system malfunction. The administrator and director of nursing (DON) 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.
- Potential for harm · E2026-05-01 · tag F0641 — patternEnsure 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 accurate MDS coding of the use of a code alert device occurred for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. Findings include:The code alert system log titled Wander Guard Monitor dated 4/2026, identified the following 14 residents as having a code alert device: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46.R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R4 had not exhibited wandering. R3's care plan last reviewed on 3/16/26 lacked interventions for elopement and wandering.R4 was admitted on [DATE]. R4's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired 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.
- Potential for harm · E2026-05-01 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop a comprehensive care plan with individualized elopement and wandering interventions with review and revision after subsequent MDS assessments or elopement status changes for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. In addition, the facility failed to care plan necessary interventions for 3 of 3 residents (R7, R14, and R26) who were addressed for care planning.Findings include: The code alert system log titled Wander Guard Monitor dated 4/2026, identified 14 residents who had code alert devices: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46. R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R4 had 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.
- Potential for harm · Ecited before2026-05-01 · tag F0880 — failed to prevent and control infections — patternProvide 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 and use of an ice scoop was followed during the snack pass. This deficient practice affected 3 of 3 residents (R29, R30, R7) and any other residents who received snacks during the snack pass. Finding include:R29's comprehensive Minimum Data Set (MDS) dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart disease, hypertension, hyperlipidemia, and gastroesophageal reflux disease.R30's quarterly MDS dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart failure (a chronic serious condition in which the heart muscle cannot pump enough blood to meet the body's needs for oxygen), diabetes mellitus and depression.R7's quarterly MDS dated [DATE], identified he was moderately cognitively intact and had diagnoses which included heart failure and diabetes mellitus.During an observation on 4/29/26 at 1:56 p.m., nursing assistant…
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.
- Potential for harm · Dcited before2026-05-01 · tag F0561 — failed to honor residents' choices — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure resident preferences for nail care were honored for 1 of 1 resident (R8).Findings include:R8's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R8 was moderately cognitively impaired with the diagnoses of non-Alzheimer's dementia, renal insufficiency, hypertension, and depression.R8's care plan last reviewed 3/26/26 indicated R8 had limited range of motion in their upper extremities and required an assist of 1 for daily bathing, weekly showers, daily grooming, oral care, and dressing.R8's progress notes indicated R8 had last had a shower on 4/3/26. Nail care was not addressed in progress notes.During an observation on 4/28/26 at 12:48 p.m., R8 was seated in wheelchair in room with their tv remote partially on their bedside table between their hands. Noted tremor in both hands, fingernails were long beyond tips of fingers. R8 stated they were trying to get their remote onto the bedside table, but their hands were so…
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.
- Potential for harm · Ecited before2025-02-14 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 4 of 5 residents (R1, R19, R7, and R13); failed to obtain signed consent with use of an antidepressant medication for 1 of 5 residents (R38); failed to implement other interventions before initiating antipsychotic medication for 1 of 5 (R38); failed to implement appropriate target behaviors for 1 of 1 resident (R1); and failed to have an appropriate diagnosis for 1 of 1 resident (R19) reviewed for unnecessary medications. Findings include: R1 R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had severe cognitive impairment, required extensive assististance with all activities of daily living (ADL's), and received antipsychotic and antidepressant medications. R1's dianoses included Alzheimers disease, age-related osteoporosis, anxiety, femur fracture, and repeated falls R1's physician orders included order for citalopram (antidepressant)…
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.
- Potential for harm · Ecited before2025-02-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure correct use of personal protective equipment (PPE) to prevent the spread of COVID. This had the potential to affect all 4 residents, visitors and staff in short term stay unit. In addition, the facility failed to develop and implement a comprehensive infection control program that incorporated virasurveillance ofl infections and illnesses not treated with antibiotics to reduce the risk of spreading infections to other residents in the facility. This has the potential to affect all 44 residents who resided in the facility. Findings include: Mask and eye protection use During observation and interview on 2/10/25, at 1:58 p.m. registered nurse (RN)-A donned (put on) personal protective equipment (PPE) prior to entering COVID positive room. RN-A removed N95 mask from paper bag, placed on face then removed goggles from same paper bag, placed on face. RN-A stated that the facility had always reused the masks and goggles, placed inside paper bags when not in use. During observation on 2/11/25, at 10:10 a.m. overbed table was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R10) reviewed and observed for self-administration of medications. Findings include: R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R3's diagnoses included heart failure, chronic kidney disease, generalized anxiety disorder, chronic obstuctive pulmonary disease, encephalopathy, hypertension and type II diabetes mellitus and unspecified dementia with psychotic disturbance. R3's physician orders included order for Ipratropium bromide inhalation solution 0.02% - 0.5 mg(milligram) - Inhale 0.5 mg via neb twice daily related to chronic obstructive pulmonary disease. During observation on 2/11/25 at 8:29 a.m., R3 was sitting in her recliner holding the nebulizer mask to her face. Nebulizer cup contained a clear…
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.
- Potential for harm · Dcited before2025-02-14 · tag F0561 — failed to honor residents' choices — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide smoking opportunities to promote quality of life and resident choice for 1 of 1 resident (R13) reviewed for choices. Findings Include: R13's Continuity of Care document (CCD) printed 2/11/25, included diagnosis of tobacco use, weakness and dementia without behavioral disturbance. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder and peripheral vascular disease. R13's electronic health record (EHR) lacked evidence R13 was asked about or assessed for smoking. Progress note dated 6/17/24, indicated R13 expressed concerns and anger towards someone confiscating her cigarettes. Progress note dated 6/29/24, indicated R13 yelled at multiple staff to take her outside and smoke. When staff refused, R13 went outside by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 complete neurological assessments following falls for 2 of 2 residents (R7 and R25) who had unwitnessed falls. Facility also failed to ensure medications were administered per physician's orders for 1 of 2 residents (R30) reviewed for bowel management and failed to ensure vitals were obtained per physician's order for 1 of 1 resident (R30) reviewed for following physician orders. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included unspecified dementia with other behavioral disturbance, malnutrition, depression, varicose veins on right lower extremity with inflammation, peripheral vascular diseases, hypothyroidism, essential hypertension, osteoarthritis and systemic sclerosis. R7's progress note dated 6/5/24 at 1:51 p.m., identified an unwitnessed fall. R7 was heard screaming and staff found her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R10) reviewed for hearing. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had moderate cognitive impairment and required assistance with most ADL's. R10's care plan, indicated R10 was hard of hearing and has difficulty with normal conversations. Care plan indicated qualified nursing staff would monitor for changes with my [R10's] abilities with communication and would offer to arrange hearing evaluation as needed. R10's electronic health record (EHR) lacked evidence R10 was offered an audiology appointment. During observation and interview on 2/10/25 at 4:04 p.m., R10 stated he had difficulty with hearing and asked surveyor to speak louder as it was really hard to hear people talking. R10 did not have hearing aides in his ears. R10 stated he had three pairs of hearing aids; one pair won't stay in ears and his daughter took the other…
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.
Show the remaining 16 citations
- Potential for harm · D2025-02-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 R25 R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R25's diagnoses included progressive neurological conditions, Parkinson's disease with dyskinesia (involuntary, erratic movements of the face, arms, legs or trunk), non-Alzheimer's dementia, anxiety disorder, adult failure to thrive and severe protein-calorie malnutrition. MDS indicated R25 was at risk for the development of pressure ulcers and currently had one stage four pressure ulcer (stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone). R25's care plan dated 1/8/25, identified R25 had a stage four pressure ulcer to right ischial tuberosity (large posterior bony protuberance on the superior ramus of the ischimum) and was at a high risk for altered skin integrity and pressure injuries and directed staff to reposition R25 every two hours while in bed and/or wheelchair. During continuous observation on 2/13/25…
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.
- Potential for harm · Dcited before2025-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 comprehensively assess to assure safety with smoking for 1 of 1 resident (R13) who was smoking outside the facility. Findings include: R13's Continuity of Care document (CCD) printed 2/11/25, included diagnosis of tobacco use, weakness and dementia without behavioral disturbance. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder and peripheral vascular disease. R13's electronic health record (EHR) lacked evidence R13 was asked about or assessed for smoking. During the facility entrance conference on 2/10/25, the administrator and the clinical manager (CM)-A stated the facility did not have any residents who smoke as the facility was a non-smoking facility. R13's care plan printed 2/11/25, did not indicate…
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.
- Potential for harm · Dcited before2025-02-14 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 development of parameters for administration of heart rate control medication was assessed and implemented with pulse monitoring to ensure the parameters were met, if needed, to decrease the risk for complications for 2 of 5 residents (R13 and R40) reviewed for unnecessary medication use. Findings include: R13 R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13 was independent with bed mobility, sitting to standing and wheeling 50 feet with two turns. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), dysphagia, unspecified mood disorder and peripheral vascular disease. R13's care plan, print date of 2/11/25, indicated R13 was at risk for impaired cardiac function related to congestive heart failure, hypertension, hyperkalemia, atrial flutter, COPD, obesity, and type two diabetes…
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.
- Potential for harm · D2025-02-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 5 residents (R30) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 10/24, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R30's face sheet, dated 2/13/25, indicated she was [AGE] years old. The immunization record dated 2/13/25, indicated R30 received the following pneumococcal…
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.
- Potential for harm · Dcited before2024-04-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 manage bowel and constipation needs for 1 of 3 residents (R2) who were reviewed. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], revealed R2 had diagnoses which included Alzheimer's Disease, constipation and had severely impaired cognition. Further, MDS assessment indicated R2 was incontinent of bowel. R2's care plan revised 12/16/23, indicated R2 was at risk for incontinence due to diagnoses of Alzheimer's disease, dementia, constipation and previous right and left femur fractures with repair. R2's goal was identified as have a large bowel movement (BM) at least every three days and interventions included: qualified nursing staff will monitor BM status daily, administer medications as ordered, and indicated R2 required staff assistance for toileting needs. R2's Bowel assessment dated [DATE], revealed R2 was occasionally incontinent of bowel and did not feel urge sensation for BM. Review of R2's output for BM revealed…
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.
- Potential for harm · Dcited before2024-04-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview and document review, the facility failed assess and implement new intervention(s) to prevent future falls for 1 of 3 residents (R2) reviewed for accidents. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], revealed R2 had diagnoses which included Alzheimer's Disease, constipation and had severely impaired cognition. Further, MDS assessment indicated R2 had two or more falls with no injuries since last assessment. R2's care plan revised 2/28/24, identified R2 was at risk for falls related to diagnoses and medications which may increase the risk for falls. R2's care plan revealed the following interventions to reduce the occurrence and injuries with falls: therapy assessment, encourage resident to wear gripper slippers at night, toileting between 3:30 a.m. and 4:00 a.m., encourage and participate in activities, ambulate with staff daily, bolstered mattress on bed, padded call light within reach and position to help alert staff when attempting to get up from bed. R2's…
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.
- Potential for harm · E2023-12-28 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure 2 of 3 medication carts and 1 of 2 treatment carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. This deficient practice had the potential to affect 46 of 46 residents who resided in the facility. Findings include: On 12/26/23 at 12:40 p.m., a grayish tan cart identified by licensed practical nurse (LPN)-A as a treatment cart, and a blueish gray cart with a light tan top and small computer screen sitting on top identified by LPN-A as a medication cart, were observed by the nursing station in the central area of the day room. The carts were unlocked and unattended by staff. Several unidentified staff, visitors, and residents observed walking past the carts. On 12/27/23, at 11:21 a.m., grayish tan treatment cart was observed unlocked and unattended in east wing hallway. Observed both unidentified residents and staff in hallway where cart was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-28 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 confidential information was not readily available for all residents, staff, and visitors to view for 20 of 20 residents whose confidential information was observed to be visible on an open computer screen in a common area. Findings include: On 12/27/23, at 4:39 p.m., trained medication aide (TMA)-B was observed to walk away from the bluish gray medication cart with electronic medical record (eMAR) documentation system open on computer screen. Resident information including names, room numbers and diagnosis from residents in north and east wings was observable on the computer screen. Medication cart was in front of the wellness room door. Several unidentified staff, residents and visitors were observed passing front of the medication cart. At 4:41 p.m. TMA-B returned to medication cart and stated the computer screen should be locked and closed when unattended. TMA-B acknowledged that they did not close out or lock the eMAR when they left the cart to administer medications. TMA-B went on to state this…
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.
- Potential for harm · D2023-12-28 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 written notice of a bed hold after transportation to the hospital for 1 of 1 residents (R43) reviewed for hospitalization. Findings include: R43's minimum data set (MDS) dated [DATE], indicated R43 has moderate cognitive impairment. Medical record failed to note bed hold discussion. During interview on 12/26/23 at 5:29 p.m., R43 stated she did not remember being requested to fill out a bed hold prior to hospitalization. During interview with nurse manager (NM)-A on 12/28/23 at 10:07 a.m., NM-A stated the facility typically did not have residents sign a bed hold when transferred to the hospital. During interview on 12/28/23 at 10:17 a.m., business manager (BM-A) stated the bed hold policy was in the admission packet. The bed hold was not typically filled out when residents were transferred to the hospital because they have not billed for the bed hold due to facility census. Undated facility document titled Bed Hold Policy, indicated that 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.
- Potential for harm · D2023-12-28 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to reassess need for rehabilitation services for 1 of 1 residents (R44) reviewed for rehab. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 was cognitively intact. Diagnoses included lymphedema (swelling of lymph nodes), intervertebral disc disorders with myelopathy (nervous system disorder that affects the spinal cord), thoracic (chest) region disc displacement, spinal stenosis in the lumbar region with neurogenic claudications (nerve disorder that causes pressure to nerve roots, leads to numbness and weakness), muscle weakness, osteoarthritis (OA), morbid obesity, and hypertrophic osteoarthropathy (syndrome that causes joint pain, swelling, and pain). Also indicated R44 required a full body mechanical lift with physical assistance from two staff for transfers and physical assistance from one staff for activities of daily living (ADL's). On 12/26/23 at 12:07 p.m., observed R44 laying on back in bed during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-28 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 provide audiology services to 1 of 1 (R29) resident reviewed for hearing. Findings include: R29's face sheet printed 12/28/23, included diagnoses of hearing loss in both ears and mild cognitive impairment. R29's care plan revised 12/16/23, indicated resident had moderate difficulty with hearing others. Intervention included to offer assistance to arrange hearing evaluation as needed. Medical record failed to note if a conversation with R29 happened. During interview on 12/26/23 at 12:42 p.m., R29 stated he would like hearing aides, but he has not been able to see a doctor regarding this concern. Resident was observed struggling to hear at conversation level, needed things to be repeated multiple times. During interview on 12/28/23 at 12:28 p.m., nurse manager (NM)-A stated she was aware resident wanted hearing aids. NM-A reported R29's daughter asked for assistance in setting up an appointment for R29 to be seen by audiology. She thought this occurred in July or August of this year (2023). During interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to identify indications (reason) for medications for 3 of 5 residents (R17, R43, and R31) reviewed for unnecessary medications. Findings include: R17's face sheet printed 12/28/23 included diagnoses of Alzheimer's disease, blindness of one eye, age-related osteoporosis, delusional disorder, chronic kidney disease, peripheral vascular disease (which reduces flow of blood to the limbs), and major depressive disorder. R17's Physician Order Report printed 12/28/23, included Milk of Magnesia 400 milligrams(mg) /5 milliliters (mL) as needed, acetaminophen 1000 mg by mouth twice a day as needed, nystatin 100,000 unit/gram apply small amount under breasts twice a day and as needed. Orders for these medications failed to indicate reason for use. R43's face sheet printed 12/28/23 included diagnoses of cerebral infarction (also known as a stroke), peripheral vascular disease, chronic kidney disease, type 2 diabetes, adjustment disorder with depressed mood, anxiety, and gastroesophageal reflux disease. R43's Physician Order Report…
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.
- Potential for harm · Dcited before2023-12-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 record review and interview, the facility failed to ensure an as needed (PRN) psychotropic (mood altering) medication order was renewed beyond 14 days without an end date. In addition, the facility failed to obtain consent for Ativan (anti-anxiety) for 1 of 5 residents (R31) reviewed for unnecessary medications. Findings include: R31's annual Minimum Data Set (MDS) dated [DATE], indicated R31 was severely cognitively impaired, had diagnoses that included Alzheimer's disease, unspecified dementia, and other behavioral disturbance. The MDS identified R31 required extensive assistance with activities of daily living (ADL's) and R31 was taking antipsychotic and antidepressant medications related to diagnoses of Alzheimer's and dementia. R31's physician order report dated [DATE], listed Ativan intensol (concentrated oral solution) 2mg (milligram) per ml (milliliter) give 1 mg every four hours (q4hr) PRN for anxiety. The order started on [DATE], however, no stop date was indicated and no consent signed. R31's…
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.
- Potential for harm · D2023-12-28 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide diet as ordered for 1 of 1 residents (R34) reviewed for therapeutic diet. Findings include: R34's Care Area Assessment (CAA) dated 7/6/23, indicated resident received pureed diet to ease chewing, okay to increase textures as tolerated. R34's diagnoses included unspecified dementia (impaired ability to remember, think, or make decisions), unspecified severity, with other behavioral disturbance. R34's physician order signed and dated 12/11/23, indicated pureed diet. Okay to increase textures as tolerated. During observation on 12/26/23, at 5:33 p.m., R34 was observed to have a solid, grayish, white substance in her mouth. Resident was not wearing dentures. Resident had no natural teeth on top and five broken teeth on bottom in the front of her mouth, all other lower teeth missing. Resident was moving substance around in mouth with her tongue, appeared to be attempting to chew. During observation on 12/27/23, at 10:33 a.m., R34 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 follow fall interventions for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had moderately impaired cognition. R1 needed extensive assist of one for bed mobility, transfers, toileting, and walking in room and corridor. R17's balance required corrective assistance from staff with transfers and ambulation. R1 had no history falls since admission and diagnoses included hypoxemia and heart failure. The group sheet dated 8/23/23, utilized by nursing assistants, identified R1 was a high risk for falls does not identify use of transfer belt use. R1's care plan dated 8/25/23, identified a diagnosis of a T8 fracture following a recent fall and was a high risk for falls. On 8/18/23, following a 8/17/23, fall the care plan was updated to include staff to place gripper socks on at night; however, the care plan lacked direction for staff to utilize a transfer…
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.
- No harm found · C2023-12-28 · tag F0732 — widespreadPost nurse staffing information every day.
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 the required nursing information was posted and updated daily. This had to potential to affect all 45 residents living in the facility, visitors, and family members who may want to review the information. Findings include: On 12/27/23 at 4:54 p.m., the staff posting hung in the central sitting area of the facility was dated 12/26/23. On 12/28/23 at 7:34 a.m., the staff posting is unchanged and dated 12/26/23 with the same information as noted on 12/27/23 at 4:54 p.m. On 12/28/23 at 9:19 a.m. observed the staff posting dated 12/26/23 had the date crossed out with black ink and replaced with 12/28/23. The information for hours worked by each discipline, register nurse (RN) and licensed practical nurse (LPN) as well as daily hour total were crossed out with black ink with new totals written in. On 12/28/23 at 11:56 a.m., director of nursing (DON) stated the staffing coordinator (SC) was responsible for posting the staff posting. [NAME] expected the SC to complete the staff posting daily based 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.
“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.
- 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.
Fines & penalties
$41,955 in federal fines across 12 penalties.
- $4,545 — penalty dated 2023-11-06
- $4,545 — penalty dated 2023-10-30
- $4,545 — penalty dated 2023-10-23
- $4,545 — penalty dated 2023-10-17
- $4,196 — penalty dated 2023-10-10
- $3,846 — penalty dated 2023-10-02
- $3,496 — penalty dated 2023-09-25
- $3,147 — penalty dated 2023-09-18
- $2,797 — penalty dated 2023-09-11
- $2,447 — penalty dated 2023-09-05
- $2,098 — penalty dated 2023-08-28
- $1,748 — penalty dated 2023-08-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| LIVING SERVICES FOUNDATION | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2018 |
| LIVING SERVICES FOUNDATION/MORA, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 02/01/2011 |
| KAMSTRA, DENNIS | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| PAKONEN, RODNEY | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| SANDERS, PAUL | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| SUNDBERG, ROBERT | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| GLEASON, JENNIFER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| PETERSON, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2019 |
| SCHWINGHAMER, JACK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2020 |
CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $567K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 245291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, 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.