Waverly Gardens
5919 Centerville Road, North Oaks, MN 55127 · Non profit - Corporation · 60 certified beds · (651) 765-4063 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 (36% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- the CMS record shows $113,312 in federal fines (most recent 2026-05-29)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 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
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 21.2% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.9% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 6.9% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.8% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.2% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.7% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.3% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.3% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.1% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.6% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.4% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.2% | 23.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.9% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.98 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.00 | 1.90 | 1.80 | better |
‡ 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.
54.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 76 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 0.69 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 54.6%CMS range 43.2–62.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 5.4–13.5 | 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 | 48.7% | 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 | 40.8% | 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 | 30.3% | 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 | 89.3% | 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 | 97.4% | 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 | 5.6% | 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 | 8.2%CMS range 4.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 60 beds and averages 57.4 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 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 4.16 hrs/resident/day on weekends vs 4.64 on weekdays — 10% thinner on weekends. RN hours go from 0.89 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
11 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · J2026-05-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure 1 of 3 residents (R1) reviewed for abuse, was free from abuse during cares on 5/16/26, when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 asked LPN-A to stop. The immediate jeopardy began on 5/16/26, when the facility failed to ensure R1 was free from abuse during cares when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 requested he stop. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 5/27/26 at 5:00 p.m. The immediate jeopardy was removed on 5/28/26, but noncompliance remained at the lower scope and severity level D (isolated, scope and severity level) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-02-07 · 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 comprehensively assess and provide the provision of supervision of self transfer to prevent and/or mitigate the risk of falls for 1 of 3 residents (R2) who had a history of falls. This resulted in actual harm for R2 who fell and sustained back and rib fractures. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was a [AGE] year-old admitted on [DATE] with diagnoses including dementia, diabetes, history of transient ischemic attack (temporary disruption of blood flow to the brain), muscle weakness, difficulty in walking, unsteadiness on feet, other abnormalities of gait and mobility, weakness, and repeated falls. R2's Brief Interview for Mental Status score was 11, indicating moderate cognitive impairment. R2 utilized a wheelchair, required substantial assistance with toileting hygiene, and moderate assistance with bed mobility and transfers. Walking was not attempted due to medical condition or safety concerns. R2 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 · D2026-05-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being abused by a staff member. Findings include: Facility Vulnerable Adult (VA) Maltreatment Report filed with State Agency (SA) dated 5/18/26 at 5:36 p.m., identified estimated date and time of most recent occurrence was 5/16/26 at 8:00 p.m. in resident bathroom. Description of incident: Allegation of sexual contact by daughter today on 5/18/26. VA complained of rectal pain before, during, and after administration of bowel evacuation regime. Daughter stated VA called her crying around 8:30 p.m. on 5/16/26 stated he hurt me! He hurt me! He put his fingers in my rectum and vagina. VA interviewed in room today 5/18/26 and she wept, I looked back at him while he was behind me and was smiling at me while he hurt me, digging around in my anus. Allegation: sexual abuse.Facility 5-day report dated 5/22/26 at 8:13 p.m., identified on 5/18/26,…
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 · D2026-05-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and protect residents during the investigation for 1 of 1 residents (R1) who reported abuse. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility on [DATE], from the hospital. R1 had moderately impaired cognition and no behaviors. R1 had functional limitations in range of motion (ROM) in upper and lower extremities on one side. R1 required substantial/maximal assistance with personal hygiene and lying to sit on bed, was dependent on staff for all transfers, repositioning in bed, toileting hygiene, and lower body dressing. R1 used a manual wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. R1's diagnoses included stroke, atrial fibrillation, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), adjustment disorder with mixed anxiety and depressed…
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 · D2024-09-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 hold, at a minimum, quarterly care conference meetings with the resident and their representative to allow the resident and/or representative the opportunity to review and participate in the revision of the care plan for 1 of 2 residents (R13) reviewed for care conferences. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 was admitted to the care facility on 8/28/24 and was cognitively intact. R13's electronic medical record (EMR) indicated the most current care conference was documented on 1/23/24. The care conference note, dated 1/23/24, indicated the care conference was held on 1/5/24 with R13's family, clinical staff, life enrichment, social services and R13 present. During an interview on 9/26/24 at 8:04 a.m., nurse manager and registered nurse (RN)-A confirmed R13 had not had a care conference since the documented care conference on 1/5/24. RN-A stated there had been a care conference set up but R13'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 · D2024-09-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 interview, and document review, the facility failed to implement interventions to prevent further development of decreased range of motion for 3 of 4 residents (R2, R4, and R28) reviewed for positioning and mobility. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted to the facility on [DATE] and had a moderate cognitive impairment and the following diagnoses: Hypertension (HTN) (high blood pressure), diabetes, hyperlipidemia (HLD) (elevated levels of fat in the blood), Parkinson's disease, epilepsy (seizure disorder), anxiety and depression. R2's Care plan dated 9/26/24, included an ambulation program to walk 400 feet with assistance twice a day. An active range of motion (ROM) program for bilateral (both sides) upper extremities five repetitions twice daily. Finally, an active ROM program to bilateral upper and lower extremities daily. The facility document R2's Tasks dated 9/26/24, where staff document the completion of tasks, included an ambulation…
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 · D2024-09-26 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 act upon the consultant pharmacist's recommendation for 1 of 5 residents (R11) reviewed for unnecessary medications. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 with diagnoses of heart failure, diabetes, dementia, and anxiety and documented R11 receiving High-Risk Drug Classes of antipsychotic, antianxiety, antidepressant, opioid, antiplatelet, and hypoglycemic medications. Also, the MDS documented R11 receiving antipsychotic on a routine and as needed (PRN) basis. In addition, the MDS documented R11 on hospice. Insulin R11's physician orders (PO) dated 8/24/24 documented, Humalog Injection Solution (fast acting insulin that lowers blood sugar in adults and children with diabetes) 100 UNIT/ML (milliliter), Inject as per sliding scale (adjusting the insulin dose based on blood glucose level) : if 200-250=2 units; 251-300=3 units; 301-350=4 units, 351-400= 5 units Call Hospice for BG>400, subcutaneously before…
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 · D2022-05-25 · 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 an intervention to prevent bruising for 1 of 2 residents (R26) reviewed for non-pressure related skin concerns. Findings include: R26's diagnoses included stroke affecting left side, chronic kidney disease, diabetes, and non-pressure chronic ulcer of the calf obtained from the admission record printed on 5/25/22. R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had moderate cognitive impairment and required extensive assist of one staff for activities of daily living. R26's care plan with a revision date of 4/7/22, indicated R26 had venous stasis ulcers (abnormal vein function) on left shin and was at risk for further skin impairment due to diabetes, impaired mobility, edema (excessive fluid trapped in the body's tissue), aspirin use, chronic kidney disease, left sided stroke, and medication side effects. R26's care plan with an initiated date of 4/6/22, further indicated R26 was to wear geri-sleeves (a product…
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 · D2022-05-25 · 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 Based on observation, interview and document review the facility failed to reposition or off load a resident timely, who had an unhealed pressure ulcer, without evidence of decline for 1 of 1 resident (R47) reviewed for pressure ulcers. Findings include: R47's annual Minimum Data Set (MDS) dated [DATE], indicated R47 was severely cognitively impaired and required extensive assistance by two staff for bed mobility, transfers and toileting. R47's MDS further indicated R47 was always incontinent of both bowel and bladder. R47's diagnoses included dementia, Meningioma (noncancerous tumor involving the brain and spinal cord), major depressive disorder, anxiety, seizures, weakness and dorsalgia (spinal/back pain). R47's Pressure Ulcer Care Area Assessment (CAA) dated 4/19/22, indicated R47 required assistance for bed mobility, pressure ulcer and incontinence and had a stage 3 (full-thickness skin loss) pressure ulcer on coccyx. R47's CAA further indicated Braden score 13 indicating risk for skin breakdown. R47's care…
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 · D2022-05-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medications were administered in accordance with physician orders without errors for 1 of 6 residents (R31) observed to receive medications. This resulted in a facility medication error rate of 18% (percent). Findings include: R31's Medication Administration Report dated 5/1/22 through 5/31/22, identified R31 had orders for: -Amlodipine tablet 10 milligrams (mg) give 1 tablet via G-tube [gastric tube] one time a day for high blood pressure -Aspirin chewable tablet 81 mg give 1 tablet via G-tube one time a day for stroke prevent. -Carvedilol tablet 3.125 mg give 3.125 mg via G-tube two times a day for high blood pressure disorder. -Escitalopram Oxalate 10 mg tablet give 10 mg via G-tube one time a day for depression. -Tylenol extra strength 500 mg tablets, give 1000 mg via G-tube two times a day for pain. -Senna-Docusate Sodium tablet 8.6-50 mg give 1 tablet via G-tube one time a day for constipation. -Polyethylene Glycol 3350 give 17 gram (1 cap full) via G-tube in the morning for constipation. 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.
- No harm found · C2024-09-26 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
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 post accessible contact information of all pertinent State agencies or Ombudsman information for 4 or 4 residents (R12, R20, R46, and R47), who routinely attend resident council. This had the potential to affect all 52 residents who resided in the facility. Findings include: During the resident council meeting held on 9/25/24 at 10:01 a.m., with a state surveyor, R12, R20, R46, and R47 participated and indicated they were regular attendees of the Resident Council meetings in the facility. Upon asking, R12, R20, R46, R47 stated they were unaware of who the ombudsman was and did not know where the ombudsman information was located or posted in the building. While on survey in the facility from 9/23/24 through 9/26/24, no posting or contact information for the Ombudsman was observed or noted within the facility or on the additional units of the nursing home and were not accessible to the residents to view or read. On 9/25/24 at 2:40 p.m., the director of Nursing (DON) and the administrator confirmed 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.
- 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
$113,312 in federal fines across 1 penalty.
- $113,312 — penalty dated 2026-05-29
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.
Part of a chain
This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 3.4 | -1.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 20 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PRESBYTERIAN HOMES AND SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/17/2020 |
| COMPUTERSHARE CORPORATE TRUST COMPANY, NA | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 07/01/2024 |
| FLETCHER, JONATHAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 02/01/2025 |
| PEDERSON, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| PETERSON, HEIDI | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| MEYER, MARK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2011 |
| PHS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/17/2026 |
| PEDERSON, JANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2021 |
| SAMMON, KATHERINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/21/2022 |
CMS files one row per role, so the 21 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 $1.5M 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 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 245613. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-26, 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.