Oak Hills Living Center
1314 Eighth Street North, New Ulm, MN 56073 · Non profit - Other · 94 certified beds · (507) 233-0800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- the CMS record shows $30,026 in federal fines (most recent 2024-04-12)
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 23.7% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.1% | 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 | 5.2% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.3% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.3% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 5.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.8% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.3% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.6% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.6% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.70 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.59 | 1.90 | 1.80 | 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.
60.5% 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 108 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.8% 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 69 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 60.5%CMS range 52.7–67.7 | 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 | 9.2%CMS range 5.3–13.8 | 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 | 63.8% | 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 | 47.8% | 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 | 52.2% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 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 | 1.2% | 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 | 5.8%CMS range 3.2–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 94 beds and averages 78.6 residents a day — about 84% occupied, or roughly 15 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 5.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.61 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.54 hrs/resident/day on weekends vs 5.57 on weekdays — 19% thinner on weekends. RN hours go from 1.29 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
10 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Jcited 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 observation, interview, and document review, the facility failed to comprehensively assess each fall and identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, failed to comprehensively evaluate and implement fall interventions for 2 of 3 residents (R1, R3) reviewed for falls. The facility's failures resulted in an immediate jeopardy for R1 who sustained a right hip fracture from the 9th fall. The IJ began on 3/28/24, when the facility failed to complete a comprehensive causal analysis, and implement appropriate interventions after R1 self-transferred to the bathroom resulting in his 9th fall from self-transfers which subsequently resulted in, hospitalization, and right hip fracture with surgical repair. The administrator and director of nursing (DON) were notified of the IJ on 4/11/24 at 6:17 p.m. The IJ was removed on 4/12/24 at 5:22 p.m. after it could be verified that the facility had implemented an acceptable removal plan,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-09-13 · 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 to safely use a mechanical lift per manufacture instruction to transfer 1 of 1 residents (R2) who required a mechanical lift for transfers. This resulted in R2 falling from a lift, sustaining major injuries. R2 subsequently died 10 days following the fall. In addition the facility failed to conduct a thorough investigation to determine the cause of the fall from the lift. This resulted in immediate jeopardy (IJ) for R2. The IJ began on [DATE], at approximately 9:30 a.m. when R2 fell from the lift during a transfer sustaining a major head injury and right upper arm fracture after two nursing assistants (NAs) were transferring a resident using the mechanical lift. The facility failed to determine the cause of the incident, continued to use the lift without a thorough inspection of the lift to determine safe for use, failed to contact the manufacturer, and failed to provide retraining and competency for staff using the lift. The administrator, director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-06-18 · 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 to implement a known safety intervention of a gait belt when ambulating a resident to prevent accident hazards for 1 of 1 residents (R1) who had a fall with major injury. This resulted in harm when R1 sustained a femur fracture. The facility corrected the deficiency prior to the survey, so the citation was issued at past non-compliance. Findings include: R1's face sheet dated 5/23/25, identified diagnoses of type 2 diabetes (condition that affects how the body uses insulin and sugar), peripheral vascular disease (narrowed arteries reduce blood flow to the arms or legs), absence of right foot, edema (swelling), and open-angle glaucoma (gradual vision loss leading to blindness). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 did not have any memory loss issues. R1 required supervision or touching assistance to walk. R1's care plan dated 4/8/21, identified R1 required use of a gait belt, walker, and assistance of one person for transfers.…
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 before2026-04-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care and shaving) was completed and provided for 1 of 1 resident (R65) reviewed for activities of daily living (ADLs) and who was dependent on staff for their care.Findings Include: R65's admission Minimum Data Set (MDS) assessment dated [DATE], identified moderate cognitive impairment, needed substantial/maximal assistance for personal hygiene including shaving and nails care; diagnoses included wedge compression fracture (spinal injury where the front (anterior) part of a vertebra collapses, forming a wedge shape while the back remains intact) of T11 -T12, hemiplegia (paralysis on one side of the body), following cerebral infarction (stroke) affecting right dominant side. R65's care plan dated 1/9/26, indicated charge nurse will provide nail care due to medical condition and hygiene interventions/ tasks indicated: wash, hands and face, shave, brush teeth, rinse mouth with mouthwash, apply…
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 · D2026-04-08 · 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 observation, interview, and document review, the facility failed to follow provider orders for leg compression for 1 of 1 resident (R38) reviewed for edema (swelling in the legs caused by fluid).Findings include:R38's face sheet dated 4/8/26, indicated diagnoses of chronic congestive heart failure, chronic respiratory failure, hypertension (high blood pressure), and obesity.R38's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, no behaviors or rejection of care, use of oxygen, use of wheelchair, supervision for hygiene, partial assistance for bathing, substantial assistance for upper and lower body dressing.R38's physician's order dated 6/25/25, indicated TG shapes (seamless tubular bandage designed to provide light, graduated compression and support) to bilateral lower extremities: on in AM and off at HS (bedtime).During interview on observation on 4/6/26 at 4:18 p.m., R38 was seated in her recliner with her legs exposed. R38 had indentations in 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 · D2024-04-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 document review the facility failed to develop and implement an individualized toileting care plan based off the comprehensive assessment for 1 of 3 residents (R1) who were identified for toileting. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment. R1 had no falls in the past six months. R1 required supervision/touch assist for sit to stand, chair to bed, bed to chair, walking, toileting, and toileting hygiene. R1 required intermittent catheterization and had not done a toileting program. R1's bladder evaluation dated 1/18/24, identified R1 had a history of urinary incontinence and urinary tract infections (UTI). R1 was frequently incontinent. Conditions impacting urinary status included pain, edema, diabetes, and urinary disorders. Physical functioning status listed one-person physical assist for bed mobility, transfer, walking, toileting, and personal hygiene. Voiding status identified R1 had the perception…
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 · D2024-04-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement an individualized toileting program based on the comprehensive assessment and failed to ensure intermittent catheterization physician orders for urinary retention were consistently followed to prevent or mitigate the risk of urinary tract infections (UTI) for 1 of 1 residents (R1) reviewed for incontinence. Findings include R1's face sheet identified R1 had diagnoses that included included fracture of right femur, vascular dementia, retention of urine, and neuromuscular dysfunction of bladder R1's significant change Minimum Data Set (MDS) dated [DATE], identified an admission date of 1/24. R1 had moderate cognitive impairment. R1 required limited assist for toilet use, and transfers. R1 was frequently incontinent of urine. A toileting program was not in place to manage urinary incontinence. R1's bladder evaluation dated 2/6/24, identified R1 had a history of urinary incontinence and urinary tract infections (UTI). R1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 83 residents who resided in the facility. Findings included: During an interview on 12/13/23 at 9:53 a.m., maintenance worker (MW)-A stated he was responsible for the facility water management program. MW-A explained the actions he took related to the water management program which included testing water for chlorine levels, measuring water temperatures at various sites in the facility, and running water in vacant resident rooms. MW-A was not aware of additional requirements of an effective water management program including completion of a Legionella risk assessment, creating a detailed diagram of the facility water system and following a nationally accepted water management program. During an interview on 12/13/23 at 10:05 a.m., findings were explained to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a jacket was offered and/or provided for a resident who rode a bus to an appointment for 1 of 1 resident (R74) reviewed for activities of daily living (ADL) . Findings include: R74's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of cares, required one person physical assistance for bed mobility, transfers, ambulation in the room, dressing, toileting, and hygiene, utilized a walker and wheelchair, diagnoses included fracture of the lower end of right radius (long bone of the forearm), muscle wasting, pain in right wrist, muscle weakness, and need for assistance with personal care. R74's care plan dated 9/29/23, indicated ADL: altered self-care performance, limited physical mobility R/T (related/to) fracture, pain, weakness, and interventions included dressing: resident requires 1 person limited physical assist with dressing skills. On 12/11/23 at 2:17 p.m., R74 stated today…
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 · D2023-09-13 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
Based on interview and document review the facility failed to immediately report an allegation of neglect to the State Agency (SA) for 1 of 3 residents (R2) reviewed for accidents. R2 fell from full body mechanical lift during a transfer resulting in a fractured arm and head injury with staples. Findings include: R2's fall incident report dated 8/16/23 at 9:52 a.m. indicated R2 was found lying across the legs of the hoyer (mechanical full body lift) on the floor with feet facing the toilet and head by the tub. R2 was noted to have a moderate amount of blood coming from the back of her head. Nursing assistants (NA)s stated that R2 was in mechanical lift sling when a loop came undone and the resident fell to the floor. R2 was unable to describe the incident. R2 was assisted to a sitting position and noted to have some pain to the right upper arm and a large part of scalp open on the right back side of head. R2 was transported by ambulance to the emergency department (ED). R2's ED notes dated 8/16/23 at 10:15 a.m., indicated R2's injuries from the fall included a fracture of the right…
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
$30,026 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $14,433 — penalty dated 2024-04-12
- $15,593 — penalty dated 2023-09-13
- Medicare payment denial — starting 2024-05-11 for 17 days
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 |
|---|---|---|---|
| BOYLE, MIKE | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2023 |
| DIETZ, BARB | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2021 |
| MARKGRAF, MICHELLE | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2022 |
| NELSON, JUDI | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2022 |
| PIESER, BEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| VARLAND, CAROLYN | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| VOGEL, ANN | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2023 |
| SCHOUVIELLER, CANDAS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 09/06/2006 |
| LOVIG, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2022 |
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.
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.
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
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
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 245490. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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.