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Cura Of Onamia

200 North Elm Street, Onamia, MN 56359 · Non profit - Corporation · 57 certified beds · (320) 738-3800 Medicare & Medicaid certified

Call the home — (320) 738-3800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Nov 2024Resident-funds citation (F0570)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0570)
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
200 Elm St N · (320) 532-3154 · Call to confirm hours
Pharmacy
516 Main St · (320) 532-3633 · Call to confirm hours
Grocery
38217 US Highway 169 · (612) 263-2170 · Call to confirm hours
Park
Onamia City Park · Typically dawn to dusk
Place of worship

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 2 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 4 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.8%18.2%15.4%better
Long-stay residents who lose too much weight7.4%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.1%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection8.1%2.6%2.0%worse
Long-stay residents with depressive symptoms3.3%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.0%4.0%3.3%worse
Long-stay residents whose ability to walk worsened7.0%20.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.7%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers7.9%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control32.3%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.5%17.1%17.1%typical

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.

Staffing

1.35
RN hours/ resident / day
0.50
LPN hours/ resident / day
1.71
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.74
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 57 beds and averages 37.7 residents a day — about 66% occupied, or roughly 19 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.35 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.71 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.81 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.60 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

5
deficiencies at the latest standard inspection (2026-04-23)
2
at the previous standard inspection (2025-02-05)

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.

ABCDEFGHIJKL

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

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-23 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident medications were properly labeled with either an expiration date or beyond use date to ensure expired medications were not administered to residents. This deficient practice had the potential to impact all residents who received medications at the facility.Findings include:During a medication pass observation on 4/21/26 at 10:30 a.m., R17's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication pass observation on 4/21/26 at 11:58 a.m., R7's medication label was reviewed. The label did not include an expiration or beyond use date.During a medication pass observation on 4/22/26 at 10:22 a.m., R1's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication observation on 4/23/26 at 7:19 a.m., R7's medication labels were reviewed. Labels did not include an expiration or beyond use date.Two medication carts were reviewed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-23 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medication injectable supplies were removed from active stock once expired. In addition, the facility failed to ensure medications were properly labeled with either an expiration date or beyond use date. These deficient practices had the potential to impact all residents who received medications at the facility.Findings include:During a medication pass observation on 4/21/26 at 10:30 a.m., R17's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication pass observation on 4/21/26 at 11:58 a.m., R7's medication label was reviewed. The label did not include an expiration or beyond use date.During a medication pass observation on 4/22/26 at 10:22 a.m., R1's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication observation on 4/23/26 at 7:19 a.m., R7's medication labels were reviewed. Labels did not include an expiration or beyond…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-23 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. This had the ability to affect all 35 residents who resided in the facility.Findings include:A facility-submitted document, received 4/21/26, identified breakfast began at 8:00 a.m., lunch began at 12:00 p.m., and dinner began at 5:00 p.m.During an interview on 4/20/26 at 2:15 p.m., the manager of nutrition services confirmed the mealtimes at the facility were 8:00 a.m., 12:00 p.m., and 5:00 p.m. The facility contracted food services through the kitchen of the attached hospital.During an interview on 4/23/2026 8:43 a.m., nursing assistant (NA)-A indicated the evening snacks were sent from the kitchen for specific residents between 6:30 p.m. and 7:00 p.m. These snacks were labeled with resident names, not all residents received them, but snacks were available to all residents upon request.During an interview on 4/23/26 at 8:47 a.m., licensed practical nurse (LPN)-A indicated dietary brought a tray for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-23 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to track and monitor residents and staff with symptoms of possible illness to prevent a possible outbreak. This could affect all residents and visitors in the facility.Findings include:During a review of the facilities infection control program paper on 4/23/26 at 8:12 a.m., the paperwork lacked any information related to staff and resident illness symptoms reported to the facility. There was no documentation of symptoms, trends in the facility or indications the facility was monitoring to prevent a potential outbreak.During an interview on 4/23/26 at 8:38 a.m., the assistant director of nursing/infection preventionist (IP) stated there had been no tracking and trending of resident or staff symptoms since she had taken over the IP program on 1/26. The IP was not aware tracking and trending of symptoms needed to be done.During an interview on 4/23/26 at 9:18 a.m., the regional clinical director (RCD) stated the facility should have a way to keep track of resident and staff symptoms. The IP should monitor that system…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-23 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident personal fund accounts were insured with adequate surety bond coverage to cover the total account balance. This had the potential to affect all 34 residents who had personal funds in the facility's trust account. Findings include: On 4/21/26 at 1:18 p.m., the residents' personal funds accounts were reviewed with the business office manager. The business office manager confirmed the total amount of the residents' accounts was in the amount of 40,688.56 dollars.On 4/22/26 at 10:02 a.m., the chief financial officer (CFO) confirmed the facility's surety bond for the residents' personal funds identified a penalty amount of 10,000 dollars. The CFO stated the bond should cover 100,000 dollars and stated they needed to reach out to their insurance [NAME] for clarification.Review of surety bond number 2653018 document dated 7/17/25, identified a surety bond for ten thousand dollars was in effect 7/23/25 and ended on 7/23/26. This document 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to assess and monitor bruising for 1 of 1 residents (R9) reviewed for impaired skin integrity. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of dementia, benign paroxysmal vertigo (a sensation of spinning or moving), inflammatory arthritis (pain, swelling and warmth in the joints) and pruritus (itchy skin). R9's care plan dated 11/21/23, identified the potential for alteration in skin integrity and directed staff to complete skin audits with showers or baths weekly. During observation on 2/3/25 at 11:52 a.m., was seated in the memory care unit dayroom area and was noted to have what appeared to be a dark purple irregular shaped bruise on the top of her left hand between the thumb and index finger approximately five centimeters (CM) in diameter. When interviewed on 2/3/25 at 11:53 a.m., R9 stated she did not remember how she obtained the bruise, denied pain and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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

    Based of observation, interview and document review, the facility failed to ensure physician prescribed medications are reviewed and monitored, for interactions between other prescribed medications, for 1 of 12 residents (R9) in the resident sample reviewed. Findings include: R9's annual Minimum Data Set (MDS) assessment of 11/11/24, identified R9 had brief interview for mental status (BIMS) score of 9, classified as moderate cognitive impairment. R9's medical diagnoses included unspecified dementia - unspecified severity without behavioral disturbance, psychotic disturbances, mood disturbance, anxiety, major depression, Gasto-esophageal reflux disease (GERD) without esophagitis and hyperuricemia (increased uric acid levels) without signs of inflammatory arthritis or tophaceous disease (monosodium urate crystals build up in the body). In review of R9's physician orders, the following medications were noted to have been ordered: Allopurinol 50 milligrams (mg) - give 1 tablet every day for hyperuricemia Diltiazem HCL 15 mg - give 1 tab three times a day for hypertension Carafate 1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an injury of unknown origin was reported immediately and/or within 2 hours, to the State Agency (SA) and administrator for 1 of 1 residents (R1). Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia, dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. Review of facility report to the SA, submitted at 11:48 a.m. on 11/24/24, by director of nursing (DON) indicated R1 had unexplained bruising to left arm. Nursing assistant (NA)-A reported R1 had bruising to left forearm, left posterior hand, and some purple coloring on the inside of left fingers, and the bruising was tender to the touch to licensed practical nurse (LPN)-A in the morning after a.m. cares on 11/23/24. LPN-A reported to registered nurse (RN)-A around 2:00 p.m. on 11/23/24, and RN-A filed a MAARC (Minnesota Adult…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a thorough investigation was completed for an injury of unknown to ensure abuse had not occurred for 1 of 1 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia (language disorder that makes it difficult to understand, speak, read, or write), dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. Review of facility report number 358743 to the SA, submitted at 11:48 a.m. on 11/24/24, by director of nursing (DON) indicated R1 had unexplained bruising to left arm. Nursing assistant (NA)-A reported R1 had bruising to left forearm, left posterior hand, and some purple coloring on the inside of left fingers, and the bruising was tender to the touch to licensed practical nurse (LPN)-A in the morning after a.m. cares on 11/23/24. Further, report indicated DON…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure bruising was monitored for changes until resolved for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia (language disorder that makes it difficult to understand, speak, read, or write), dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. R1's Progress Notes revealed: -On 11/23/24 at 2:35 p.m., large amount of bruising was reported by nursing assistant. R1 was unable to state what happened. -On 11/24/24 at 11:48 a.m., resident had a 7-centimeter (cm) x 7 cm bruise to proximal and posterior left forearm, bruise was purple in the center with green around the edges, bruise was slightly raised and tender to the touch. Bruise 2 cm x 1.8 cm to distal posterior forearm dark purple in color. 3 cm x 4 cm bruise to posterior (back) of left…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · D2024-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure process's were followed for safe lift transfers for 1 of 6 residents (R1) reviewed for safety with mechanical stand transfers. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, and was dependant on staff for transfers. R1 had a height of 60 and weighed 198 pounds (lbs) diagnoses included stroke, hemiparesis or hemiplegia, and seizure disorder, R1's care plan dated 11/5/23, directed staff to transfer R1 with EZ-stand (sit to stand lift). R1's undated, Care Sheet directed staff to transfer R1 with EZ-stand and large sling. A Facility Reported Incident (FRI) dated 1/29/24, identified R1 had a fall during a transfer to the bathroom. R1 was being transferred from the EZ-stand when the left side of the sling slipped off. R1 was lowered from the EZ-stand and assisted to the floor. It was a witnessed fall and no injuries. The facility investigation dated 1/29/24, indicated R1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a physician ordered medication was acquired timely from the pharmacy to prevent delay in administration and reduce the risk of complications for 1 of 1 residents (R1). This resulted in R1's anticoagulant (blood clot prevention) medication being omitted for six consecutive days. In addition, the facility failed to ensure procedures were implemented and followed to ensure sufficient medication supplies, timely medication re-ordering, after hours on-call pharmacy use, and appropriate action(s) taken when a medication was not available for administration. Findings include: A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on 1/19/24 at 9:45 a.m. and identified R1's ordered Xarelto (anticoagulant) medication was reordered on 1/5/24 from the pharmacy; however, the medication was not delivered and thus, R1's Xarelto was omitted on 1/6/24 through 1/11/24. In addition, the report indicated her medical record lacked…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-09 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705D identified the following dates triggered: 7/2/23, 8/20/23, 8/26/23, 8/27/23, and 9/4/23 for failure to have licensed nurse coverage 24 hours per day. Daily staff schedules on the above-mentioned dates identified licensed nursing staff including registered nurses had worked and therefore the data submitted in the PBJ to CMS was inaccurate. During interview on 1/8/24 at 8:41 a.m., administrator stated the reporting was the facility's error as the agency staff are not reflected in the report. During interview on 1/9/24 at 12:10 p.m., administrator stated the payroll coordinator generates a report from the payroll system, with information on report that is uploaded in the PBJ portal. Administrator…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 routinely provide and document range of motion (ROM) exercises to maintain and prevent decline in current physical functioning for 1 of 1 resident (R18) reviewed for restorative therapies. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderately impaired cognition and diagnoses of multiple sclerosis (a chronic disease that affects the central nervous system but attacking myelin, a substance that protects nerve cells) and paraplegia (paralysis of the legs and lower body). R18 needed extensive assistance with activities of daily living (ADL's). R18 had impairments to both sides of upper and lower extremities and no rejection of cares. R18's care plan printed 1/9/24, indicated that R18 would participate in maintenance nursing range of motion (ROM) exercises to bilateral (both sides of body) upper and lower extremities daily. R18's physician orders printed 1/9/24, indicated maintenance nursing: ROM exercises 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-09 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess for and identify past trauma (PTSD) for 1 of 1 resident (R8) who had a history of multiple past traumatic experiences. Findings include: R8 was re-admitted the the facility from Senior Services (geriatric-psych services - SCS) on 11/14/23 where he had been admitted due to behaviors of striking out, yelling, biting and other threatening behaviors. R8's admission Minimum Data Set (MDS) dated [DATE], identified resident as being severely cognitively impaired, Alzheimer's type dementia, and behaviors were noted in the look back period. R8's Behavior Care Area Assessment (CAA) worksheet (dated 11/20/23) documented the following: Resident's behavior symptoms not currently directed at other residents. Behaviors occur most with staff and with cares. He will swear, verbally and physically threaten, hit or kick out, grab on to things and not let go. At this point, cares have been able to be competed. The CAA went on to document: Resident has some trauma…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CURA — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 2 of 52.0≈ chain avg
The other 7 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CURAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/22/2025
DIRKES, MARKIndividualMANAGING CONTROL - GOVERNING BODYsince 07/22/2025
KNUTSON, ANDREWIndividualMANAGING CONTROL - GOVERNING BODYsince 07/22/2025
OPATZ, TOMIndividualMANAGING CONTROL - GOVERNING BODYsince 07/22/2025
STRUZYK, FREDIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNFsince 07/22/2025
BURR, DENNISIndividualCORPORATE DIRECTORsince 07/23/2025
DUBBS, ROBERTIndividualCORPORATE DIRECTORsince 07/23/2025
GRAVEL, LOUISIndividualCORPORATE DIRECTORsince 07/23/2025
HASS, ANTHONYIndividualCORPORATE DIRECTORsince 07/23/2025
VIRNIG, ARDENIndividualCORPORATE DIRECTORsince 07/23/2025
TF MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/22/2025
ANDERSON, KAYLAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/24/2025
BRACKEN, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
DOLINSKY, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/24/2025
MILLE LACS HEALTH SYSTEMOrganizationADP OF THE SNFsince 07/22/2002

CMS files one row per role, so the 20 rows in the source record cover these 15 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.

What families pay in MN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245127. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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