Benedictine Living Community Owatonna
2255 30th Street NW, Owatonna, MN 55060 · Non profit - Corporation · 79 certified beds · (507) 444-4200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- inspectors recorded 3 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $36,638 in federal fines (most recent 2024-10-24)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.3% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.5% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.9% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 6.0% | 4.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.2% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.7% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 2.2% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.3% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.4% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.8% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.9% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.1% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.3% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.7% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.54 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.10 | 1.90 | 1.80 | worse |
‡ 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.
58.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 237 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.3% 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 143 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 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.2%CMS range 51.2–63.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.4–14.0 | 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 | 78.3% | 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 | 59.4% | 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 | 81.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 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 | 1.3% | 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 | 7.4%CMS range 5.0–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.76 | 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 79 beds and averages 74.5 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 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 3.64 hrs/resident/day on weekends vs 4.24 on weekdays — 14% thinner on weekends. RN hours go from 1.05 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
39 citations, most serious first. The 14 most serious are shown; the remaining 25 are one tap away and print in full.
- Immediate jeopardy · J2024-10-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 observe the rights of medication administration to ensure the right medication was safely administered for 1 of 3 residents (R2) reviewed for significant medication errors. This resulted in an immediate jeopardy for R2 who required hospitalization, continous monitoring and intravenous fluid recovery to return to baseline. The immediate jeopardy (IJ) began on 10/16/24 when licensed practical nurse (LPN)-A injected R2 with 100 units (U) of short-acting insulin instead of the prescribed Heparin (blood thinner that prevents blood clots) 5,000 milliliter (ml). The Administrator, Director of Nursing (DON), and clinical nurse manager were notified of the IJ on 10/23/24 at 5:13 p.m. The IJ was issued as past non-compliance (PNC) when facility implemented immediate corrective action prior to survey entrance to prevent recurrence. Findings include: R2's Continuity of Care document dated 10/23/24, identified R2 had diagnoses that included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to safely use a mechanical lift per manufactures recommendations to transfer 1 of 1 resident (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to sustain a fractured sternum and left pelvic hematoma that required a hospital admission and blood transfusion. The IJ began on 7/21/24 at 9:40 p.m., when staff failed to ensure lift sling was properly secured prior to the transfer causing R1 to fall from the mechanical lift. The administrator, regional nurse manager, and director of nursing (DON) were notified of the IJ on 7/24/24 at 4:13 p.m. The IJ was removed on 7/22/24, when the facility implemented immediate corrective action before survey to prevent recurrence, therefore, the IJ was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1' had intact cognition R1 used a motorized wheelchair, 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.
- Actual harm · Gcited before2026-05-13 · 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 educate on risk and prevention of deep vein thrombosis (DVT); failed to ensure applied compression wraps for DVT prevention were clarified upon admission for ongoing use; and failed to ensure physician orders for resumption of anticoagulant (blood thinning) medication were acted upon timely to help reduce the clotting risk for 1 of 3 residents (R1) reviewed. R1 was subsequently hospitalized and died due to severe blood clotting with an ischemic (insufficient blood flow) leg and pulmonary embolism (clot in the lung) resulting in actual harm for R1. In addition, the facility failed to ensure surgical incisions were adequately monitored by nursing staff to reduce the risk of complication (i.e., delayed response to infection) for 1 of 3 residents (R2) reviewed who had surgical wounds. Findings include: R1: R1's Hospitalist Discharge summary, dated [DATE], identified R1 would be transitioned to the care center and listed a principal problem…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure safe transfers with a full body mechanical lift for 1 of 3 residents (R1) reviewed for falls/safety. This resulted in actual harm when R1 fell from the lift, had severe back pain, and needed to be sent to the emergency department (ED) for evaluation. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's face sheet dated 7/9/25, identified diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), acquired absence of left leg above the knee, and burst fracture of the T11-T12 vertebrae (a serious spinal injury when the vertebra breaks). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was dependent on staff for all transfers and cognitively intact. R1 had no falls since previous assessment.R1's Safe Lifting and Movement assessment dated [DATE], identified R1 had an amputation, paraplegia, 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.
- Potential for harm · Dcited before2026-05-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to develop a baseline care plan to ensure immediate care needs for surgical incision care and his urinary incontinence were addressed for 1 of 3 residents (R2) reviewed. R2's progress note, dated 4/13/26, identified R2 admitted to the care center and had several medical conditions including peripheral arterial disease (PAD), acute kidney injury, chronic kidney disease (CKD), and high blood pressure. R2 needed assistance for all activities of daily living (ADLs), needed cues and reminders to ask for help, and was alert and oriented to self. The note identified R2 had been incontinent of urine and was unaware of such. Further, the note included a section labeled Skin that identified, . two healing surgical sites in bilateral groin . Bruising to BUE [bilateral upper extremities] . Small scabbed area to posterior calf on LLE [left lower extremity . All areas OTA [open to air] and not draining. No redness, swelling, or warmth to peri-wounds. R2's Care Plan, dated 4/22/26, identified all the potential or actual problems R2 had,…
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 · D2026-05-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess and, if needed, develop a toileting program to promote urinary continence and reduce the risk of complication (i.e., skin infection, breakdown) for 1 of 3 residents (R2) reviewed. On 5/12/26 at 12:35 p.m., R2's family member (FM)-D was interviewed. R2 was admitted to the care center after being hospitalized for an extended period due to multiple conditions and he had used a catheter while in the hospital, but it was removed before he discharged to the care center on 4/13/26. FM-D stated R2 was doing good with using the bathroom and able to sense the need to go when he left the hospital. R2 also had some healing surgical incisions near his groin which were all intact and open-to-air (OTA). However, then they opened while at the care center and R2 had to eventually go back to the hospital due to them being re-opened and becoming infected. FM-D stated the family had visited at times and found R2 to be incontinent of urine which…
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 · D2026-05-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 document review, the facility failed to ensure high-risk medications were provided timely after being ordered to help prevent potential blood clots for 1 of 1 resident (R1) reviewed. R1 had Eliquis (an anticoagulant, blood thinning, medication) ordered by the medical doctor (MD)-A on 4/10/26; however, this was not provided to R1 until 4/12/26 despite supply of the medication available in the emergency kit (E-Kit) onsite. R1's Hospitalist Discharge summary, dated [DATE], identified R1 would be transitioned to the care center and listed a principal problem, Acute cholecystitis (gallbladder inflammation). R1's other active problems included high blood pressure, heart failure, and atrial fibrillation (irregular heart rhythm). R1 was described as a [AGE] year-old female who admitted to the hospital on [DATE] with acute cholecystitis and underwent surgery for this condition. R1 then developed atrial fibrillation with rapid ventricular rate (RVR). The summary outlined, Eliquis on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely implement physician's order to administer an anti-nausea medication and timely follow an order for transfer to emergency department for 1 of 3 residents (R1) which resulted in delay of treatment reviewed for change of condition. Findings includeFindings include:R1's face sheet dated 3/25/26, identified diagnoses of perforation of intestine (non-traumatic) (hole or tear develops in the intestine), and colostomy status (surgical opening in colon that allows stool to exit through stoma).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive issues. R1 had no behaviors. R1 used a walker and wheelchair for mobility. R1 required one staff assistance with dressing, transfers, repositioning, toileting, and walking. R1 had an ostomy.During a phone interview on 3/25/26 at 8:37 a.m., nursing assistant (NA)-B stated on 2/27/26, around 4:00 p.m.-4:30 p.m. she emptied R1's colostomy bag. Afterward, she walked R1 out to dinner. Five…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day for 1 of 1 resident (R2) reviewed for hospice services.Findings include:R2's face sheet dated 10/31/25, identified diagnoses of heart failure (a condition where the body's heart does not pump enough blood for the body's needs), atrial fibrillation(a common heart rhythm disorder), and anxiety disorder (a mental health condition defined by excessive worry and fear).R2's admission Minimum Data Set, dated [DATE], identified R2 was dependent for all transfers, received hospice services, and was cognitively intact.R2's hospice focus care plan dated 8/14/25, identified R2 received hospice services with a goal of preferred wishes for end of life to be honored. Interventions were as follows: facility will coordinate with hospice providers and reference hospice care plan located…
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 · E2025-07-24 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure proper food temperatures and provide attractive food in order to ensure palatability for 15 of 15 residents (R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, R78, and R90) reviewed for concerns of cold food. In addition, the facility failed to provide palatable food for 4 of 4 residents (R22, R25, R47 and R78) reviewed for dining. This had the potential to affect all residents who ate food provided by the facility. Finding include: R2's significant change in status Minimum Data Set Assessment (MDS) dated [DATE], indicated severe cognitive impairment. R25's quarterly MDS dated [DATE], indicated severe cognitive impairment. R26's quarterly MDS dated [DATE], indicated cognitively intact. R29's quarterly MDS dated [DATE], indicated cognitively intact. R45's comprehensive MDS dated [DATE], indicated cognitively intact. R52's comprehensive MDS dated [DATE], indicated cognitively intact. R55's quarterly MDS dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure care was provided in a dignified manner for 1 of 2 residents (R24) reviewed for dignity, when the resident was left in bed, unclothed. Findings include:R24's face sheet provided on 7/24/25, included diagnoses of hemiplegia (weakness or partial paralysis on one side of the body) following a stroke.R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had moderately impaired cognition, clear speech, could understand and be understood. R24 required partial or substantial assistance with activities of daily living and did not walk. R24's physician order dated 7/3/24, indicated to apply barrier cream to penis and scrotum daily, 6:30 a.m. - 11:00 a.m.R24's care plan with revised date of 7/10/25, indicated R24 needed assistance with dressing, personal hygiene, and bathing due to decline in mobility related to but not limited to hemiplegia.During an interview on 7/21/25 at 3:52 p.m., R24 stated that morning an agency nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-24 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to provide a method for residents and resident representatives to submit grievances anonymously. In addition the facility failed to follow their grievance process for missing/damaged personal property for 1 of 1 resident (R69) who reported a missing item. This had the potential to prevent all 72 residents in the facility.Findings include: On 7/23/25 at 11:20 a.m., during resident council R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, R78 each stated that they were unaware of any method to submit concerns anonymously and stated that no anonymous grievance process had been made known to them. On 7/23/25 at 3:00 p.m., during a facility tour, social services (SS)-A confirmed there was no grievance box or any other designated area for anonymous grievance submission accessible to residents available in resident accessible locations. Further, no signage or posted information indicated an option for submitting concerns confidentially or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R26) reviewed for mood and behaviors, specifically post traumatic stress disorder (PTSD). Findings include: R26's face sheet printed 7/24/25, indicated diagnoses of major depressive disorder and post traumatic stress disorder.R26's care plan revised 7/10/25, indicated the potential for trauma responses related to military service in Vietnam, as evidenced by anxiety around fireworks and being around other people. Interventions included ensuring clear paths to doors if resident was in a room with multiple people and honoring wishes regarding position of entry door.R26's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors, and lacked a diagnosis for post traumatic stress disorder.During observation on 7/23/25 at 10:00 a.m., R26 was observed entering chapel A for a dietary meeting.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 that medications were administered in accordance with accepted professional standards and failed to disinfect the rubber septum of an insulin pen with an alcohol wipe prior to attaching the needle and administering insulin for 1 of 1 resident (R87) observed during insulin administration. Findings include: R87's face sheet printed 7/24/25, indicated R87 was admitted on [DATE], and diagnosis included type 2 diabetes.R87's care plan dated 7/22/25, indicated alteration in nutrition/hydration related to diabetes and obesity and medications reviewed quarterly and prn (as needed). R87's medication administration history dated 7/1/25-7/24/25, indicated Novolog Flex Pen U-100 Insulin; insulin pen; per sliding scale.On 7/22/25 at 12:30 p.m., licensed practical nurse (LPN)-A was observed preparing to administer a subcutaneous insulin injection to R87 using a prefilled insulin pen. LPN-A removed the pen cap and immediately attached the needle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 25 citations
- Potential for harm · D2025-07-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 1 resident (R54) brief was changed according to his care plan, and who was reviewed for activities of daily living (ADLs).Findings include:R54's face sheet provided on 7/24/25, included diagnoses of dementia and Alzheimer's disease. R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had moderately impaired cognition, clear speech, could understand and be understood. R54 was always incontinent of bowel and bladder and was dependent upon staff for toileting. R54 did not walk. R54's care plan with edited date of 7/10/25, indicated R54 had urinary incontinence. Care plan approach with edited date of 6/2/25, indicated R54 was on a toileting plan; to check and change brief with AM (morning) and HS (evening), before and after meals and activities and per resident or family request and PRN (as needed). Every Shift: Day 06:00 AM - 02:00 PM, Evening 02:00 PM - 10:30 PM, Night 10:30 PM - 06:00 AM. Care plan dated 4/7/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · 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 implement a process to ensure that the resident received their scheduled insulin dose while out of the facility for 1 of 1 resident (R90) reviewed for medication administration.Findings include:R90's admission Minimum Data Set Assessment (MDS) assessment dated [DATE], indicated R90 was admitted [DATE], cognitively intact, required supervision with personal hygiene, sit to stand, toilet transfer, utilized a walker and wheelchair, diagnoses included: diabetes, seizure disorder and anxiety.R90's care plan dated 7/24/25, indicated R90 receives an insulin that places them at risk as a high risk medication, monitor for signs and symptoms of hyperglycemia and hypoglycemia; visual impairment related to cataracts as evidenced by difficulty reading fine print writing, legally blind in my left eye, provide large print reading materials or talking books as needed; alteration in nutrition/hydration related to DM (diabetes mellites), anxiety, pain,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure an insulin pen included resident name and dated when opened for 1 of 1 resident (R87) reviewed for medication administration. Findings include: R87's face sheet printed 7/24/25 indicated R87 was admitted on [DATE], and diagnosis included type 2 diabetes.R87's care plan dated 7/22/25, indicated alteration in nutrition/hydration related to diabetes and obesity and medications reviewed quarterly and prn (as needed). R87's medication administration history dated 7/1/25-7/24/25, indicated Novolog Flex Pen U-100 Insulin; insulin pen; per sliding scale three times a day before meals and Toujeo Solostar; 50 units; subcutaneous at bedtime.On 7/22/25 at 12:30 p.m., during observation of medication administration, licensed practical nurse (LPN)-A was observed entering R87's room and unlocking the medication cabinet. LPN-A removed a NovoLog FlexPen insulin pen from the cabinet, attached a needle, primed the pen with two units, dialed to nine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure appropriate treatment and services for a Foley catheter for 1 of 1 resident (R11) reviewed for catheter cares. In addition, the facility failed to follow proper infection control practices for 1 of 1 resident (R54) observed during peri care. Findings include: FOLEY CATHETER CARE R11's face sheet printed 7/24/25, included diagnosis of acute kidney failure, and obstructive and reflux uropathy (blockage in urinary system) and benign prostatic hyperplasia (enlarged prostrate) with lower urinary tract symptoms. R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R11 had moderately impaired cognition, was dependent on staff for bathing, toileting, dressing and transfers and R11 had a Foley catheter. R9's care plan dated 7/11/25, identified R11 had a indwelling Foley catheter with interventions including keep catheter tubing free of kinks, keep drainage bag below bladder level, maintain a closed catheter drainage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 4 of 9 residents (R8, R7, R9 and R6) observed during a medication pass. In addition, the facility failed to ensure proper cleaning of glucometer for 1 of 3 residents (R6) and failed to utilize enhanced barrier precautions (EBP) for 2 of 2 residents (R1 and R5) during wound dressing changes. Findings include: R8's face sheet dated 10/24/24, identified diagnoses of type 2 diabetes mellitus (condition that affects how the body uses sugar as fuel). During an observation on 10/23/2024 at 7:15 a.m., Licensed practical nurse (LPN)-C entered room for R8. Hand hygiene was not performed prior to entering room. The glucometer was removed from locked medication cabinet, along with strips, alcohol pad, and cotton ball. LPN-C applied gloves without performing hand hygiene, assisted R8 to reposition with same gloved hands, then obtained blood sugar. LPN-C then removed gloves and did not perform hand hygiene prior to leaving R8's room. R7's face sheet dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · 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 observation, interview, and record review the facility failed to revise the care plan for 2 of 9 residents reviewed (R1, R5) who had non-pressure related skin injuries. Findings include R1's face sheet dated 10/23/24, identified diagnoses of contusion to the head, fracture of facial bones, laceration without foreign body right lower leg, and nontraumatic subarachnoid hemorrhage. R1's care plan dated 9/16/23, identified R1 was at risk for falls related to history of falls and dependent on staff for transfers and ambulation. R1's progress note dated 10/10/24 at 7:04 p.m., identified R1 fell forward out of chair and landed on pavement with wheelchair landing on top of her. Lacerations to forehead, and cheek, bruising and swelling along with bleeding to nose, bleeding noted in mouth, large laceration to right shin/calf. 9-11 called to escort via ambulance to ED for evaluation. The care plan did not identify R1's impaired skin integrity nor a plan of care that included goals and individualized interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · 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
Based on observation, interview, and record review the facility failed to comprehensively assess, monitor, and notify the physician of new wounds for 2 of 3 residents (R1, R5) who had non-pressure related skin injuries. Findings include R1's face sheet dated 10/23/24, identified diagnoses of contusion to the head (bruise to the brain), fracture (break) of facial bones, laceration (cut) without foreign body right lower leg, and nontraumatic subarachnoid hemorrhage (bleeding below the arachnoid layer of the brain). R1's brief interview and staff assessment for mental status (BIMS) dated 7/29/24, identified R1 had severe cognitive impairment. R1's care plan dated 9/6/23, identified a potential for impaired skin integrity. Interventions included dressings per wound nurse or as ordered, monitor skin integrity weekly with showers, report to Nurse Practitioner (NP) or Medical Doctor as needed. R1's progress note dated 10/10/24 at 7:04 p.m., identified R1's chair rolled off the curb at approximately 6:30 p.m. R1 fell forward out of chair and landed on pavement with wheelchair landing on top…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-06 · 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 record review the facility failed to follow the care plan for transfers for 1 of 3 residents (R1) who sustained a fall as a result. Findings include: R1's face sheet dated 9/6/24, identified R1's diagnoses included hemiplegia and hemiparesis affecting right dominant side (affect movement and sensation on one side of the body), metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction), muscle weakness, and epilepsy (brain disease that causes repeated seizures due to abnormal electrical signals). R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 required substantial assistance to transfer from one position to another. R1's care plan dated 5/20/24, identified R1 required assist of one staff with non-mechanical sit to stand aid for all transfers. R1's care plan dated 7/24/24 identified R1 required assist of two with non-mechanical sit to stand aid for transfers. Both interventions were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-24 · 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 observation, interview and document review, the facility failed to ensure the administrative staff and State Agency (SA) were notified immediately but no later than 2 hours of an allegation of neglect for 1 of 1 resident R1 who fell from a mechanical lift. Findings include: A facility reported incident was submitted to the state agency (SA) on 7/22/24, at 1:34 p.m. The incident report identified R1 experienced fall during transfer from chair to bed. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition, with diagnoses of muscle weakness. R1 was dependent on staff for transfers, took anticoagulants and had no history of falls. R1's progress note dated 7/21/24 at 9:40 p.m., indicated R1 had a fall from a mechanical lift the resulted in skin tears to her right index and middle fingers and left bicep area. During an interview on 7/24/24 at 1:01 p.m., director of nursing (DON) indicated that she was made aware of R1's fall that had occured on 7/21/24 on 7/22/24 at 8:03 a.m. 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.
- Potential for harm · Dcited before2024-06-28 · 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 observation, interview, and document review the facility failed to revise the care plan for 1 of 4 residents (R1) observed who were identified to have behavioral issues not addressed in the care plan. Findings include R1's Continuity of Care Document (CCD) dated 6/27/24, identified an admission date of 10/22/21. Medical diagnoses included anxiety disorder, dementia (deterioration of memory, language, and other thinking abilities), restless leg syndrome (overwhelming urge to move legs, usually associated with unpleasant sensations often during sleep and relieved by movement), pain, arthritis (condition that affects the joints causing pain, stiffness, and reduced movement), abnormalities of gait and mobility, history of falling, and weakness. R1's Behavior Observation assessment (annual) dated 3/20/24, identified a section titled 'Other behavior symptoms not directed toward others' and to note presence of symptoms and frequency. The assessment indicated R1's behaviors included disrobing in public and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to ensure the infection control program used enhanced barrier precautions (EBP) for 5 of 5 residents (R7, R19, R9, R62 and R57) who had wounds or indwelling device present. Finding include: R7's care plan dated 3/12/24, indicated R7 required total assist with two staff for all transfers with Hoyer lift, related to weakness caused by history of multiple sclerosis and total assist to toilet related to weakness caused by history of multiple sclerosis, has a Supra pubic catheter in place. R33's care plan dated 5/17/24, indicated R33 had a pressure injury to coccyx and wound treatments and orders. On 6/4/24 at 11:15 a.m. nursing assistant (NA)-B was in R33's room and provided a bed bath for R33. NA-A confirmed R33 had an open sore on her buttock that was covered with a dressing. NA-B stated no gowns or gloves were required when assisting R33 with cares or transfers. NA-B stated the facility had not provided education PPE including gown and gloves was required when cares or transfers were completed for residents with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure proper infection control practices were followed, specifically hand hygiene, when culinary aides were observed failing to wear clean gloves or failing to wear gloves when handling food. This had the potential to impact all 30 residents who resided on Kindle and Oak units. Findings include: During a dining observation on the Kindle unit on 6/3/24, from 5:27 p.m. to 5:58 p.m. observed culinary aide (CA)-A dish up food from the steam table onto plates for residents. CA-A was wearing gloves as he dished up food, handled multiple paper diet slips, (initially handled by nursing assistants [NAs] when residents selected their meal options), opened cupboard doors, and the freezer. Then without removing his gloves, washing his hands, and donning clean gloves, CA-A put several pieces of bread in the toaster. Once the bread was toasted, CA-A spread peanut butter on it and delivered it to the residents seated at the dining table. CA-A returned to the kitchenette to continue serving food. During an interview on 6/3/24 at 5:58 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R57) who required a general soft and bite size texture diet. Findings Include: R57's face sheet dated 4/22/24, included diagnoses of hemiplegia and hemiparesis (mile to complete loss of strength on one side of the body) following cerebral infarction (stroke) affecting right dominant side. R57's Minimum Data Set (MDS) dated [DATE], indicated R57 usually is understood and understands. R57 had no behaviors and requires set up and cueing with eating and has no swallowing difficulty. R57's provider orders dated 3/25/24, included thin liquids, and 5/21/24, soft and bite size texture meals. R57's care plan dated 4/1/24, included alternation in nutrition/hydration related to multiple medical problems that may affect nutritional intakes. Interventions included diet as ordered. Honor food preferences as able. Feeding assistance as needed. During observation of the noon meal on 6/4/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 2 of 2 residents (R62, R23) reviewed for mood and behaviors, specifically post traumatic stress disorder (PTSD). Findings include: R62's Face Sheet printed 6/6/24, indicated admission date was 1/26/24, and diagnoses included spinal stenosis with neurogenic claudication (space around the lower spine narrows causing pressure on the spinal cord and nerves that go through it), depression and post traumatic stress disorder (mental health condition that develops following a traumatic event). R62's quarterly Minimum Data Set (MDS) dated [DATE], section I, active diagnosis list did not include post traumatic stress disorder. R23's Face Sheet printed 6/6/24, included an active diagnosis of post-traumatic stress disorder (PTSD), dated 7/28/16. R23's quarterly MDS assessment dated [DATE] section I, active diagnosis list did not include post traumatic stress disorder.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 offer/provide a summary of the baseline care plan to the resident and/or resident representative for 2 of 2 residents (R57, R35) reviewed who were newly admitted to the facility. Findings include: R57's Face Sheet dated 4/22/24, identified an admission date of 3/25/24 and readmission on [DATE], with diagnoses of cerebral infarction (stroke) affecting right dominant side, heart failure, corticobasal degeneration (areas of the brain shrinks with nerve cells breaking down and dying) abdominal pain, aphasia (inability to speak well), major depressive disorder and generalized anxiety disorder. R57's admission Minimum Data Set (MDS) dated [DATE], identified R57 had clear speech and usually is understood and understands. R57 is wheelchair dependent and walking was not assessed. R57 had impairment on both upper extremities. R57 was cognitively intact and had no behaviors. R57's care plan dated 5/20/24, indicated R57 was at high risk for falling and required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · 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 ensure staff provided restorative services to meet the assessed needs for 1 of 2 residents (R35) reviewed for restorative services. Findings include: R35's face sheet printed on 6/5/24, indicated diagnoses of idiopathic peripheral autonomic neuropathy (damage of nerves that causes numbness, pain and balance issues), osteoporosis (bones become weak and brittle), repeated falls and unsteadiness on feet. R35's significant change Minimum Data Set (MDS) assessment dated [DATE], included R35 is understood and understands, has intact cognition, no behaviors including refusal of care and requires supervision for transfers, walking in her room and hallways 10 to 50 feet. R35's care plan dated 6/4/24, indicated R35 is limited in wheelchair mobility related to debility and is on the walk list. Interventions included ambulation two times per day with assist of one, using front wheeled walker, distance as tolerated with a wheelchair to follow. A progress note…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess a resident for safe vaping practices for 2 of 2 residents (R7, R23) reviewed for accidents. Findings include: R7's annual Minimum Data Set, dated [DATE], indicated R7 exhibited rejection of care one to three days out of seven, dependent on staff for toileting, lower body dressing, chair to bed transfer, toilet transfer; required substantial/maximal assistance with shower, eating, oral hygiene, independent with motorized wheelchair/scooter, diagnoses included multiple sclerosis (disabling disease of the brain and spinal cord), depression, no tobacco use, and no history of falls. R7's care plan dated 3/12/23, indicated R7 had diagnosis of Multiple Sclerosis and currently prescribed medical cannabis in which family obtains and resident administers independently, facility to follow policy relating to MN law and Statute 152.21-.37. Progress note dated 1/19/24 at 2:20 p.m., social services (SS)-B indicated he attempted to…
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 · D2024-06-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with the use of distilled water for 1 of 1 resident (R62). Findings include: R62's face sheet printed 6/6/24, included diagnoses of heart failure, spinal stenosis with neurogenic claudication (space around the lower spine becomes narrowed causing pressure on the spinal cord and nerves resulting in pain, numbness and difficulty walking or standing), and obstructive sleep apnea (OSA-sleep-related breathing disorder causing the airway to become obstructed and occasional to frequent cessation of breathing). R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 was cognitively intact and required extensive assist of two for bed mobility and transfers. Special treatments did not include CPAP. R62's plan of care dated 1/29/24, did not include a respiratory plan of care or the use of a CPAP machine. R62's physician orders…
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 · D2024-06-06 · tag F0699 — isolatedProvide 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 observation, interview, and document review, the facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for 2 of 2 residents (R64, R23), reviewed who had an active diagnosis of post-traumatic stress disorder (PTSD). Findings include: R23's Face Sheet printed 6/6/24, included an active diagnosis of post-traumatic stress disorder (PTSD) (mental health condition that develops following a traumatic event), dated 7/28/16. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 understands and is understood. A Brief Interview for Mental Status (BIMS) indicated a score of 0 indicating severe cognitive impairment. R23 had behaviors that included verbal behavioral symptoms directed towards others 4 to 6 days, but less than daily. R23 had rejection of care 1 to 3 days. R23 required substantial/maximal assistance with transfers, and toileting and was dependent for bed mobility and transfers. R23 was taking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-03 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure agency nursing assistants (NA's) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 78 residents residing in the facility. Findings include: During an interview on 8/2/23 at 07:21 a.m., (NA)-A stated the facility used a lot of agency nursing staff including NA's. NA-A stated at times, there were more agency staff on duty than employed staff. NA-A stated the weekend of 7/29/23 to 7/30/23, on the 2:00 p.m. to 10:00 p.m., two new agency NA's started: (NA)-C and (NA)-D. NA-A stated they came one hour early to receive an hour of orientation before caring for residents on their own. NA-A was required to provide the one-hour orientation while also caring for 17 residents on the unit. NA-A stated one hour was not enough time to show and explain everything to an agency NA before their shift. Further, NA-A stated NA-C had told her she was a new NA and did not know how to use the sit-to-stand transfer aid (a piece of equipment used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in 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 act promptly and respond timely to concerns raised at resident council meetings for 5 of 10 residents, (R11, R50, R25, R6, R26) who attended council meetings. Findings include: The last twelve months of resident council minutes were requested. Minutes from 4/18/22 to 5/18/23, were received, indicating a total of seven meetings had occurred over the span of 15 months. Minutes reflected residents raised concerns, but those concerns were not followed up on at the next meeting. The minutes did not reflect who at the facility would be responsible for follow up on a particular concern. During a resident council meeting on 8/3/23 from 10:10 a.m. to 10:45 a.m., R50 whose quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, stated the resident council met irregularly. R6 whose quarterly MDS assessment dated [DATE], indicated intact cognition, added meetings were not well attended, but when the ombudsman attended a meeting a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-03 · 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 observation, interview and document review the facility failed to implement interventions to prevent potential worsening of contractures for 1 of 2 residents (R17) reviewed for contractures. Findings include: R17's diagnoses located on the physician order sheet dated 7/14/23, included: cerebral infarction (obstructive blood flow to the brain), unspecified hemiplegia (paralysis of partial or total body function on one side of the body) and physical debility (state of general weakness). R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition. R17 required extensive assist with activities of daily living (ADL's) that included personal cares. The MDS identified R17 as having impairment of range of motion (ROM) on both sides of the upper and lower extremeties. R17's current care plan reviewed on 6/29/23, identified R17 as having skin alteration and poor tissue integrity related to impaired mobility, diabetes, stroke and hand contractures. The care plan identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and develop individualized interventions to address exhibited behaviors of dementia for 1 of 1 resident (R43) observed to wander on unit and reported to go into other residents' rooms. Findings include: R43's significant change in status Minimum Data Sheet (MDS) assessment dated [DATE], indicated R43 had severely impaired cognition, had severely impaired vision and moderate difficulty hearing, had clear speech, sometimes understood by others, sometimes understands others, required extensive assistance of one person for all activities of daily living (ADL) needs, had an unsteady gait, used a wheelchair for mobility needs, and had frequent falls with minor injuries. The MDS further indicated R43 displayed daily behaviors including hallucinations (altered perception of reality), delusions (false beliefs), wandering, rejection of care, exhibited daily physical and verbal behaviors towards others, was taking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure medications were securely stored, permitting only authorized personnel to have access for 4 of 4 residents (R62, R28, R37, R172) reviewed for medication storage. This had the potential to affect residents, visitors and staff who had access to the resident rooms. Findings include: Each resident at the facility had a wooden medication storage cupboard attached to a wall in their room. Each cupboard had a keyhole affixed to it. During observations on 7/31/23 between 2:25 p.m. and 4:10 p.m., on the Kindle unit, the medication storage cupboards in R62, R28, R37 and R172's rooms were noted to be unlocked with medications inside. R62's unsecured medication included: -- Timolol maleate 0.5% (for glaucoma), 1 drop both eyes once a day between 6:30 a.m. and 11:00 a.m. One bottle of drops. R28's unsecured medications included: -- Albuterol sulfate inhalation solution (for lung diseases), 2.5 milligrams (mg)/3 milliliters (ml) every six hours PRN (as needed). One box of vials. -- Pulmicort Flexhaler (for lung diseases), 90 mcg…
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 · C2025-07-24 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure that the posted nurse staffing information accurately reflected the actual number of nursing assistants (NA) and the total number of hours worked for posted schedules. This had potential to affect all 74 residents or visitors who wished to review the information.Findings include: On 7/22/25 at 1:28 p.m., the posted nurse staffing information was observed posted in the hallway across from the main reception area. The posted information included shift, category of shift, shift times scheduled and staffing hours. 10 CNAs scheduled from 6:00 a.m. to 2:00 p.m. with 65 staffing hours, and1 CNA from 6:00 a.m. to 12:30 p.m. with 6 hours, totaling 81 hoursThe actual staffing schedule for 7/22/25, reviewed concurrently, indicated:1 CNA from 7:55 a.m. to 2:00 p.m. (7 hours and 5 minutes), and8 CNAs from 6:00 a.m. to 2:00 p.m. (72 hours total),Resulting in 79 hours and 5 minutes, not the 81 hours posted.On 7/22/25 at 1:58 p.m., the staffing hours posted was observed with the director of nursing (DON) and the 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$36,638 in federal fines across 2 penalties.
- $22,205 — penalty dated 2024-10-24
- $14,433 — penalty dated 2024-06-06
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 BENEDICTINE HEALTH SYSTEM — 23 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 | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 22 homes this chain runs (chain average 2.8★, 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 | Since |
|---|---|---|---|
| FRUEHBRODT GLENZINSKI, JUDY | Individual | CONTRACTED MANAGING EMPLOYEE | since 01/01/2024 |
| KERN, LISA | Individual | CONTRACTED MANAGING EMPLOYEE | since 11/14/2019 |
| BRUHN, JENNIFER | Individual | CORPORATE DIRECTOR | since 11/25/2019 |
| BURETTA, PATRICIA | Individual | CORPORATE DIRECTOR | since 04/23/2024 |
| DRAEGER, ANNE | Individual | CORPORATE DIRECTOR | since 06/08/2021 |
| KOTTKE, MATTHEW | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| MILLER, SANDRA | Individual | CORPORATE DIRECTOR | since 01/10/2017 |
| OBERG, JAMES | Individual | CORPORATE DIRECTOR | since 08/01/2018 |
| RETHEMEIER, JULIE | Individual | CORPORATE DIRECTOR | since 07/27/2023 |
| RYMANOWSKI, KEVIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 06/11/2009 |
| SLIETER, RICHARD | Individual | CORPORATE DIRECTOR | since 08/01/2018 |
| WOLF, CHRIS | Individual | CORPORATE DIRECTOR | since 01/24/2024 |
| BERGIEN, TRICIA | Individual | CORPORATE OFFICER | since 02/21/2017 |
| BENEDICTINE HEALTH SYSTEM | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2010 |
| CARLEY, GERALD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/18/2017 |
CMS files one row per role, so the 16 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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 $946K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245426. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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.