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River Valley Health And Rehabilitation Center LLC

200 South Dekalb Street, Redwood Falls, MN 56283 · For profit - Corporation · 43 certified beds · (507) 637-5711 Medicare & Medicaid certified

Call the home — (507) 637-5711 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,310 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,310 in federal fines (most recent 2025-01-27)
  • nursing-staff turnover (84%) runs well above the national median (45%)

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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
39648 BIA-3 · (507) 697-8600 · Call to confirm hours
Pharmacy
1110 E Broadway St · (507) 637-3492 · Call to confirm hours
Grocery
1111 E Bridge St · (507) 637-8332 · Call to confirm hours
Park
501 S Gould St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.2%18.2%15.4%better
Long-stay residents who lose too much weight2.0%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.9%1.9%0.9%typical
Long-stay residents with a urinary tract infection1.8%2.6%2.0%typical
Long-stay residents with depressive symptoms2.1%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury7.9%4.0%3.3%worse
Long-stay residents whose ability to walk worsened8.6%20.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.9%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers4.2%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control23.4%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.4%1.9%1.4%typical
Short-stay residents given the seasonal flu vaccine48.0%82.7%79.4%worse

§ 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.

12.3%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 91% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 7.8–18.610.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS 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

1.39
RN hours/ resident / day
0.21
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
1.01
RN hoursweekends
83.7%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 43 beds and averages 33.3 residents a day — about 77% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.39 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.79 on weekdays — 16% thinner on weekends. RN hours go from 1.54 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 84% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

4
deficiencies at the latest standard inspection (2026-03-24)
6
at the previous standard inspection (2025-02-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2025-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to comprehensively assess proper full body mechanical lift sling type and size according to manufacturer recommendations to ensure safety for 1 of 1 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a history of behaviors during lift transfers, fell from the lift and suffered a shoulder fracture. The immediate jeopardy began on 1/19/25, when staff used a hygiene (toileting) sling that was too large causing R1 to experience pain resulted in behaviors and fell through the lift sling to the floor. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 5:00 p.m. on 1/27/25. The facility implemented immediate corrective action on 1/19/25 to prevent recurrence, so the IJ was issued at past none compliance. Findings include: A facility Reported Incident (FRI) submitted to the state agency (SA) on 1/19/25 at 12:40 p.m., alleged potential caregiver neglect when R1 fell through…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-03-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 notify the medical provider with a change in condition for 1 of 1 resident (R33) reviewed for notification of change. Finding include:R33's face sheet provided on 3/24/26, included diagnosis of heart disease. R33's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R33 required supervision or partial assistance for most activities of daily living.R33's physician orders did not include an order for transfer to the hospital. Facility standing orders did not provide guidance for transfer to the hospital. R33's care plan did not include focus areas for heart disease or respiratory concerns.Progress notes indicated no documentation that a provider had been notified for three consecutive transports to the local emergency department (ED):--On 2/22/26 at 2:15 p.m., R33 was transported by ambulance to the ED for bilateral lung crackles, wheezing and shortness of breath.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-24 · tag F0641 — isolated
    Ensure 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 accurately code the presence of a pressure ulcer on the admission Minimum Data Set (MDS) assessment for 1 of 3 residents (R20) reviewed for pressure ulcers. Findings Include: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 was admitted to the facility on [DATE], no cognitive impairment, required supervision with personal hygiene, and dependent with dressing, toileting, and transfers; diagnosis included pressure ulcer of sacral region unspecified stage, and Section M-Skin Conditions indicated R20 had no unhealed pressure ulcers/injuries. R20's Interim Payment Assessment MDS dated [DATE], indicated one or more unhealed pressure ulcers, and one stage 3 pressure ulcer. R20's care plan dated 1/19/26, indicated pressure injury to buttocks and interventions included; Monitor skin integrity daily during cares, .weekly skin inspection by nurse , treatment to open areas per order. R20's hospital summary report dated 1/15/26, indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow ordered wound care treatments, failed to ensure availability and use of ordered supplies, and failed to notify the provider when treatments were not completed for a pressure-related wound for 1 of 3 residents (R10) reviewed for pressure ulcers. Findings include: R10's discharge assessment - return anticipated Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment, required substantial/maximal assistance with personal hygiene, dependent on assistance with transfers, utilized a wheelchair, diagnoses included sepsis, burn of third degree on the buttock; unhealed pressure ulcers/injuries, one stage 3 pressure ulcer that was present upon admission/entry or reentry. R10's entry tracking MDS dated [DATE], indicated on 3/16/26, R10 was readmitted from a short-term general hospital. R10's care plan revision dated 3/17/26, indicated pressure ulceration to R (right) buttock and R dorsum foot and interventions 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 interview and document review, the facility failed to administer a physician-ordered medication for 1 of 1 resident (R37), when lorazepam (used to treat anxiety) was not administered. The facility did not notify the provider or leadership, or implement an alternative intervention, resulting in a medication omission for several days. Findings include:R37's face sheet provided on 3/24/26, included diagnoses of congestive heart failure (when heart muscles cannot pump enough blood to meet the body's needs) and generalized anxiety. R37's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R37 was either independent or needed partial assistance for most activities of daily living and was independent with walking. R37's handwritten physician order dated 12/12/25, (no time listed) indicated to start lorazepam 0.25 mg (milligram), 7:00 a.m. and 7:00 p.m. R37's care plan dated 11/10/24, indicated R37 was at risk for alteration in comfort 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-13 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 a registered nurse (RN) was on duty a minimum of eight consecutive hours per day for four of 30 days reviewed for RN coverage. This had the potential to affect all 35 residents residing at the facility. Findings include: Review of the nursing staff schedules from 4/13/25-5/13/25, identified there was no RN that worked for a minimum of eight hours per day. During an interview on 5/13/25 at 12:35 p.m., scheduling coordinator (SC)-A stated the facility was supposed to have an RN scheduled eight hours per day. It had been difficult lately, but she tried her best to fill the gaps utilizing facility staff, corporate agency staff, and outside staffing agencies. There had been gaps with RN coverage on the weekends recently. SC-A reviewed the schedules and identified there was no RN coverage for the facility on 4/27/25 (Sunday), 5/4/25 (Sunday), 5/10/25 (Saturday), and 5/11/25 (Sunday). SC-A stated the facility currently only had two RN's in-house, and had to rely on outside sources to fill the gaps in coverage, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Fcited before2025-02-05 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the nursing staff schedules and time punches for 8/29/24, 9/8/24, 9/28/24, 9/29/24 and 1/11/25 identified there was no evidence an RN had worked for a minimum of 8 hours per day. Interview on 2/5/25 at 11:23 a.m., with RN-B identified the facility was short on RN coverage and either she or the director of nursing (DON) would attempt to cover those shifts as charge nurse or floor nurse, however some days no replacements could be assigned. She confirmed for the above dates, there was no RN working. Interview and document review on 2/5/25 at 12:38 p.m., with the administrator confirmed the facility failed to provide consecutive 8 hours per day of RN coverage on the above mentioned dates due to the lack of available RN staff. The facility had been attempting to recruit staff, and they also had staff hired who then…

    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.

    Nursing and Physician Services Deficiencies · Waiver has been granted
  • Potential for harm · F2025-02-05 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to submit accurate staffing data based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the July 2024, Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Frequently Asked Questions, located at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/pbj-policy-manual-faq-11-19-2018.pdf, identified reporting shall be based on the employee ' s primary role. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out when needed). Facilities shall still report just the total hours of that employee based on their primary role. However, CMS recognizes that staff may completely shift their primary role in a given day. For example, a nurse who spends…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 timely notify the physician of new onset pressure ulcers for 1 of 1 resident (R7). Findings include: R7's 11/15/24, annual Minimum Data Set (MDS) identified R7 was cognitively intact and had a diagnosis of dementia, anxiety, depression, psychotic disorder (impaired relationship with reality, confusion, hallucinations and delusions) and malnutrition. R7 was at risk for pressure ulcer development and no pressure ulcers at the time of the assessment. R7 required supervision or touching assistance with bed mobility, transfers, and toileting. R7 had an indwelling catheter during the look back period. R7's current, undated, care plan identified on 8/9/24, he was noted to be at risk for alteration in mobility related to weakness and dementia. At that time, R7 was independent with bed mobility, had grabs bars to assist with bed mobility, could safely enter and exit his bed, and was independent with locomotion in his wheelchair. R7's 11/14/24,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 document review, the facility failed to ensure ventilator equipment supply water was not expired for 1 of 1 (R18). Findings include: R18's [DATE], annual Minimum Data Set (MDS) identified R18 had a diagnoses of respiratory failure and chronic obstructive pulmonary disease (COPD) and was cognitively intact. R18 had used a non-invasive mechanical ventilation system, along with 02 therapy. R18's current, undated care plan identified R18 used a ventilator for her COPD. The nursing staff were directed to replace the tubing and 02 chamber, clean and inspect the tubing, and notify the respiratory company of any damage to the machine or if there staff had any concerns. Observation and interview on [DATE] at 12:19 p.m., with licensed practical nurse (LPN)-A while in R18's room and later in the storage room, identified R18 had a ventilator (a non-invasive ventilator with a mask used to assist COPD patients with easier breathing) which sat on the table next to R18's bed. The ventilator…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 assess and meet the needs of 1 of 1 (R7) resident reviewed for the provision of medically related social services, who was grieving the death of a significant other. Findings include: R7's 11/15/24, annual Minimum Data Set (MDS) identified R7 was cognitively intact and had a diagnoses of dementia, anxiety, depression, psychotic (impaired relationship with reality, confusion, hallucinations and delusions) disorder and malnutrition. R7 had little interest or pleasure in doing things and had trouble falling or staying asleep or sleeping too much 12 to 14 days. R7 had felt down, depressed, hopeless, had a poor appetite, felt bad about himself, or have let himself or his family down, had trouble concentrating on things, moving or speaking slowly that other people would not have notice, and thoughts that R7 would be better off dead or wanting to hurt himself in some way never to 1 day. R7's current, undated care plan identified R7 was at risk for alteration of mood and behavior. Staff were to provide redirection,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2025-02-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 personal protective equipment (PPE) was used during a sterile dressing change for 1 of 1 resident (R85). Findings include: R85 was admitted on [DATE] for orthopedic aftercare with diagnoses of infection in his left hip following an arthroplasty, ( a surgical procedure to replace a joint with an artificial one), absence of his left hip joint, rheumatoid arthritis, and local infection of his skin and subcutaneous tissue. 85's admission orders identified staff were to follow Enhanced Barrier Protections ((EBP), infection control (IP) control practices that use PPE to reduce the spread of multi-resistant organisms (MDROs)), while caring for IV lines and during performance of high contact personal cares. R85 had a peripherally inserted central catheter ((PICC), a flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart). through which his antibiotic medication was administered. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 2 of 5 residents (R21, R31) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccinations. Findings include: R21's Minimum Data Set (MDS) dated [DATE], indicated R21 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnoses of renal failure and diabetes which puts her at higher risk for pneumococcal diseases. It further indicated her pneumococcal vaccinations were up to date. R21's Minnesota Immunization report dated 12/5/24, indicated R21 received the pneumococcal polysaccharide vaccine (PPSV 23) on 9/20/12 and the pneumococcal conjugate vaccine (PCV13) on 10/20/17. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/4/25, identified based on R21's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-07 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 35 residents. Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. Observation on 2/7/24 at 1: 58 p.m. of the staff breakroom identified there was no signage related to a PIP project posted in the staff breakroom. Interview on 02/7/24 at 2:00 p.m., with trained medication aide (TMA)-E identified she was unaware what a PIP project is and could not recall ever being trained to 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-07 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to provide mandatory training on the facility's specific QAPI Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the potential to affect all 35 residents. Findings include: Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. Observation on 2/7/24 at 1: 58 p.m. of the staff breakroom identified there was no signage related to a PIP project posted in the staff breakroom. Interview on 02/7/24 at 2:00 p.m., with trained…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-07 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed include with their Abuse Prohibition/Vulnerable Adult policy reporting of reasonable suspicions of a crime and coordination with the QAPI program to define how staff will communicate situations of abuse, neglect, misappropriation of resident property and exploitation for review and oversight. Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that identified on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported the HR director at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 on the stand lift in R2's bathroom. The picture showed NA-B posing with R2 in the resident's bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation when showing NA-A the picture. The report identified that the staff involved had been immediately suspended pending an investigation. There had been no other agencies notified at the time. R2's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to ensure 1 of 1 resident (R2) was free from potential psychosocial abuse using the reasonable person concept when R2's family reported R2 would have been severely embarrassed and angry when R2 had a photograph taken of her by staff while being toileted. Findings include: Review of 1/30/24, the nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of an incident where nursing assistant (NA)-A had reported the HR director on 1/29/24 at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 in the residents bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation. The report identified that the staff involved had been immediately suspended pending an investigation. There had been no other agencies notified at the time. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to follow or revise and/or update facility policies and ensure reports to the State Agency (SA) not later than 2 hours after alleged abuse, neglect, exploitation or mistreatment for 1 of 1 resident (R2) after the facility had knowledge of the incident. The facility further failed to revise and/or update their policy to include to report reasonable suspicion of a crimes against a resident receiving care at the facility to the local law enforcement, or what those may entail. Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator made a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported the HR director at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 on the stand lift in R2's bathroom. The picture was shown to NA-A while the staff were charting cares at the table in the common area. The picture showed NA-B posing with R2 in the resident's bathroom hooked up to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R2). Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported to the HR director on 1/29/24 at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 in the residents bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation. The report identified that the staff involved had been immediately suspended pending an investigation. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 1 resident (R2) with new onset mental illness. Findings include: R2's [DATE], admission Record identified that R2 had been admitted to the facility in [DATE]. R2's [DATE], annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's prior MDS's had no identification of a psychotic disorder. R2's diagnosis list printed [DATE], identified a new diagnosis of unspecified psychosis not due to a substance or known physiological condition on [DATE]. R2's care plan printed [DATE], identified at risk for alteration in mood related to dementia with behavioral…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop a comprehensive care plan for 3 of 3 residents (R1, R2 and R3) reviewed who were diabetic (a condition preventing the body's ability to process food leading to dangerously high or low blood sugar levels) when the care plan did not identify potential diabetic complications and specific diabetic preventative health concerns related to diet, skin, vision, and foot care. R1's nursing home admission orders dated 12/11/19, indicated R1 received three different diabetic medications along with an order to check her blood glucose level two times a day. R1's medical order dated 1/14/21, indicated a new order to change her current regular diet to a diabetic diet. R1's care plan dated 1/12/22, indicated she had a risk for pain related to her diabetes. The care plan did not identify potential diabetic concerns involving her blood sugar levels or diabetic preventative health concerns related to diet, skin, vision, and foot care. R1's quarterly Minimum Data…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$14,310 in federal fines across 1 penalty.

  • $14,310 — penalty dated 2025-01-27

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 MONARCH HEALTHCARE MANAGEMENT — 45 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 3 of 53.7-0.7 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 44 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Hillcrest Health Care, LLCMankato, MN 1 of 5Maplewood Rehabilitation CenterMaplewood, MN 1 of 5The Emeralds At Fairbault LLCFaribault, MN 1 of 5The Emeralds At Grand Rapids LLCGrand Rapids, MN 1 of 5The Emeralds At St Paul LLCSaint Paul, MN 1 of 5The Estates At Excelsior LLCExcelsior, MN 1 of 5The Estates At Lynnhurst LLCSaint Paul, MN 1 of 5The Villas At BrookviewGolden Valley, MN 1 of 5The Villas At New BrightonNew Brighton, MN 1 of 5The Villas At Osseo LLCOsseo, MN 1 of 5The Villas At RobbinsdaleRobbinsdale, MN 1 of 5The Villas At The CedarsSaint Louis Park, MN 1 of 5The Waterview Pines LLCVirginia, MN 1 of 5The Waterview Shores LLCTwo Harbors, MN 1 of 5The Waterview Woods LLCEveleth, MN 1 of 5Villas At Bryn Mawr LLCMinneapolis, MN 2 of 5Bayside Manor LLCGaylord, MN 2 of 5Oaklawn Health Care, LLCMankato, MN 2 of 5Parmly On The Lake LLCChisago City, MN 2 of 5The Estates At Chateau LLCMinneapolis, MN 2 of 5The Estates At Fridley LLCFridley, MN 2 of 5The Estates At Roseville LLCRoseville, MN 2 of 5The Estates At Rush City LLCRush City, MN 2 of 5The Estates At Twin Rivers LLCAnoka, MN 2 of 5The Gardens At Foley LLCFoley, MN 2 of 5The Gardens At Winsted LLCWinsted, MN 2 of 5The North Shore Estates LLCDuluth, MN 2 of 5The Villas At St Louis ParkSaint Louis Park, MN 2 of 5The Villas At St PaulSaint Paul, MN 2 of 5The Villas At The ParkSaint Louis Park, MN 3 of 5Bethany On The Lake LLCAlexandria, MN 3 of 5Laurels Peak Health Care, LLCMankato, MN 3 of 5Meeker Manor Rehablitation Center, LLCLitchfield, MN 3 of 5The Estates At Bloomington LLCBloomington, MN 3 of 5The Estates At St Louis Park LLCSaint Louis Park, MN 3 of 5The Villas At RichfieldRichfield, MN 3 of 5The Villas At RosevilleRoseville, MN 4 of 5Lakeshore Rehabilitation Center LLCWaseca, MN 4 of 5Mala Strana Health Care, LLCNew Prague, MN 4 of 5Sleepy Eye Rehabilitati CenterSleepy Eye, MN

Showing 40 of 44; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
NIJ LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST14%since 08/22/2019
SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST32%since 08/22/2019
WBS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/22/2019
HALPERT, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 08/22/2019
JAFFA, NOAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 08/22/2019
LEGUM, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEENO PERCENTAGE PROVIDEDsince 08/22/2019
STERN, WILLIAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 08/22/2019

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.2M
Net patient revenuemost recent cost report
+6.6%
Operating marginrevenue minus expenses
$623K
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 8%Other / private 30%

This home reported $623K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$355per resident / day
operating cost
$10,797per month
≈ monthly operating cost
$380per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245237. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-24, 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.

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