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The Villas At The Park

4415 West 36 1/2 Street, Saint Louis Park, MN 55416 · For profit - Corporation · 52 certified beds · (952) 927-9717 Medicare & Medicaid certified

Call the home — (952) 927-9717 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0605) — most recent Nov 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$144,586 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $144,586 in federal fines (most recent 2025-11-20)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4301 Highway 7, Ste 155 · (763) 755-4275 · Call to confirm hours
Pharmacy
4220 Park Glen Rd · (888) 888-7109 · Call to confirm hours
Grocery
4214 Minnetonka Blvd · (952) 217-4355 · Call to confirm hours
Park
3015 Raleigh Ave S · (952) 924-2600 · Typically dawn to dusk
Place of worship
5224 Minnetonka Blvd · (952) 926-1646

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.4%18.2%15.4%better
Long-stay residents who lose too much weight7.7%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%2.6%2.0%better
Long-stay residents with depressive symptoms9.1%4.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.3%4.0%3.3%worse
Long-stay residents whose ability to walk worsened5.4%20.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.4%12.5%18.9%typical
Long-stay residents given the seasonal flu vaccine85.4%96.1%95.3%worse
Long-stay residents with pressure ulcers7.8%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control18.5%24.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.4%17.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine52.2%82.7%79.4%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.

46.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.2%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
0.23U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.2%CMS range 31.5–60.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.2–15.310.7%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 identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 SNFs0.851.02Oct 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

0.67
RN hours/ resident / day
0.33
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.16
Total nurse hours/ resident / day
0.59
RN hoursweekends
36.6%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 52 beds and averages 48.4 residents a day — about 93% 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.26 on weekdays — 10% thinner on weekends. RN hours go from 0.71 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-11-20)
8
at the previous standard inspection (2024-10-24)

Deficiencies are unchanged from the previous inspection. 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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-11-20 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a resident received appropriate interventions to prevent contractures for a resident who was admitted to the care facility without contractures (permanent shortening of tissue, such as muscle, tendon or skin leading to the inability to straighten joints fully and to permanent deformity and disability) for one of two residents (R20) reviewed for range of motion. This resulted in actual harm when R20 developed severe contractures of bilateral upper and lower extremities. Findings include:R20s significant change Minimum Data Set (MDS), dated [DATE], indicated R20 was admitted to the care facility on 3/20/19. The MDS indicated R20 was not on any range of motion or restorative nursing programs. R20's previous MDS dated [DATE] further indicated R20 had range of motion impairment on only one side of his body and also lacked any mention of a range of motion or nursing restorative program. The MDS dated [DATE] further indicated R20 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-10-24 · 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 The State Operations Manual (SOM) defined the various presure ulcers as follows: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. It may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) are not present. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the skin and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-20 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    During observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on 1 of 3 mobile medication carts. This had the potential to affect 14 residents (R3, R4, R9, R14, R27, R28, R30, R32, R35, R40, R43, R47, R48, and a discharged resident) on the long-term care unit whose personal information was left unattended on a medication cart in the hallway corridor. Findings include:During observation and interview on 11/19/25 at 9:05 a.m., an unattended medication cart had a form titled East nursing care sheet with 13 resident names, room numbers, and notations including other personal information such as nutritional needs such as tube feeding, blood sugars, blood pressures, heart rates, recent falls with confusion and wearing adaptive equipment. Electronic medical record (EMR) access username, password, and wifi information was also included. In addition, the cart had an opened narcotic logbook with two residents' information including name, room number, and narcotic dosage…

    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 · D2025-11-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 ensure a resident (R20) was assessed and care planned for a dignified toileting experience for a continent resident who was told to wet himself for toileting.Findings include:R12's admission minimal data set (MDS), dated [DATE], indicated R12 was admitted to the care facility on 10/29/25, had moderate cognitive impairment and required extensive assistance with most activities of daily living (ADLs).R12's diagnoses list, dated 10/29/25 indicated R12 as admitted to the care facility with a primary diagnosis of sequelae of cerebral infarction (long term conditions post stroke).R12's bladder evaluation, dated 11/4/25, indicated R12 had functional incontinence which could be related to the following impaired mobility, manual dexterity impairment, lack of toilet or toilet substitute, use of restraints, medications. R12's care plan, dated 11/6/25, indicated R12 transferred with the assistance of an easy stand (a machine that lifts an individual…

    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 · D2025-11-20 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 obtain and document an informed consent, including with explanation of risk and benefits, for 2 of 5 residents (R7, R12) reviewed for use of psychotropic medications. Findings include:R7 R7's admissions Minimum Data Set (MDS) dated [DATE] identified R7 with severely impaired cognition, dependent for all cares, and diagnoses of anoxic brain damage (loss of oxygen to the brain for a period of time resulting in damage), seizures, schizophrenia, and dysphagia (impaired swallowing). In addition, R7 had a feeding tube for nutrition. R7 physician orders dated 8/18/25 identified: Haloperidol [psychotropic] Oral Tablet 5MG, Give 5mg via G-Tube two times a day for . related to SCHIZOPHRENIA,UNSPECIFIED (F20.0);CATATONIC SCHIZOPHRENIA (F20.2). R7's medication administration records (MARs) identified R7 was administered Haloperidol August 2025: 51 doses, September 2025: 60 doses, October 2025: 61 doses, missing dose on October 29 8:00 a.m. timeslot, November…

    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 · D2025-11-20 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 in interview and document review, the facility failed to ensure a resident had an appropriate diagnosis and indication for use for a prescribed antipsychotic medication for one of five residents (R12) reviewed for unnecessary medications. Findings include:R12's admission minimal data set (MDS), dated [DATE], indicated R12 was admitted to the care facility on 10/29/25, had moderate cognitive impairment and had received antipsychotic medication during the 7-day lookback period.R12's diagnoses list, dated 10/29/25, indicated R12 was at the care facility with a primary diagnosis of sequelae of cerebral infarction (long term conditions post stroke).R12's physician orders, dated 10/29/25, indicated R12 had an order for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) at bedtime.R12's November medication administration record (MAR) indicated R12 had received a dose of Seroquel every evening that month for a total of 19 doses.R12's electronic medical record (EMR) lacked evidence R12 had an appropriate…

    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 · D2025-11-20 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a bed bound resident was care planned for, and received, adequate activities for social and mental stimulation for one of two residents (R20) reviewed for activities. Findings include:R20s significant change minimal data set (MDS), dated [DATE], indicated R20 was admitted to the care facility on 3/20/19 and was dependent on staff for all activities of daily living. The MDS further indicated R20 was not assessed for activity preferences nor did staff complete an activity assessment. R20's diagnoses list indicated R20 had several medical diagnoses including aphasia and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dated 4/19/20.R20's Census report indicated R20 was admitted to hospice services on 7/24/24 and revoked hospice on 10/10/25.R20's Activity Participation Review, dated 9/18/25, indicated R20 preferred to listen to his favorite music in his room and watch[es] TV. He likes to have…

    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 · D2025-11-20 · tag F0811 — isolated
    Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
    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 residents requiring assistance with eating were provided services by qualified staff for 1 of 1 residents (R47) reviewed requiring a mechanically altered diet.Findings include: R47's quarterly Minimum Data Set (MDS), dated [DATE], indicated R47 had severe cognitive impairment and was dependent on staff for assistance with eating. The MDS indicated R47 was on a mechanically altered diet and utilized a feeding tube.R47's care plan dated 7/2/25, indicated R47 required assistance from staff with eating. R47's speech therapy discharge note dated 10/7/25, indicated R47 had a diagnosis of dysphagia, respiratory failure, and a traumatic brain injury. The note from the speech therapist recommended R47 be on a minced & moist (food consists of small, soft lumps) diet with thin liquids. The note indicated R47 required staff supervision/assistance at mealtime to swallow safely. The note indicated R47 should be sitting at 90 degrees while…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 binding arbitration agreements of 1 of 3 residents (R23) were clearly communicated in a form and manner that they understood prior to signing the forms. Findings include:R23's quarterly Minimum Data Set, dated [DATE] identified R23 with intact cognition and no impairment in memory or mood.Record review of R23's MN admission Packet in her electronic medical record (EMR) identified admission to facility on 1/20/23, however it was electronically signed 11/17/25, by both R23 and the social services director (SS-D).During interview with R23 on 11/18/25 at 10:56 a.m., R23 verified she had been a resident of the facility since January of 2023 and had no memory issues. R23 stated she was aware of what arbitration is and defined it as, arbitration is when you have a dispute of some kind and both sides agree to have somebody to listen to both sides. Let them decide instead of going to a jury. R23 stated no one from the facility spoke to her on 11/17/25…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self administration assessment (SAM) and a physician's order was completed to allow a resident to safely administer their own medication for 1 of 1 resident (R18) observed with medication at the bedside. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had intact cognition, and cardiorespiratory conditions, pneumonia, respiratory failure, asthma, chronic obstructive pulmonary disease, or chronic lung disease. R18's Medical Diagnosis form undated, indicated R18 had chronic respiratory failure with hypoxia (low oxygen levels in the body), pneumonia due to other gram-negative bacteria, obstructive sleep apnea, dyspnea (shortness of breath), other specified chronic obstructive pulmonary disease, emphysema, and bronchiectasis (a condition where the airways widen and causes coughing with mucus and frequent infections) uncomplicated. R18's Physician Orders form indicated the following 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 freedom of movement was not restricted when multiple pillows were placed by nursing staff adjacent to the resident's body, blocking the egress section of a perimeter mattress, underneath the fitted sheet which could not be removed easily by the resident for 1 of 1 resident (R104) reviewed for potential restraints. Findings include: R104's admission Minimum Data Set (MDS) dated [DATE], identified he had severely impaired cognition, and hallucinations and delusions had occurred. There was no behavior directed toward others and no rejection of care. Diagnoses included traumatic brain injury and anxiety. Falls occurred prior to entry but none since admission. Trunk restraints were not used. Extensive assist of two staff were required for bed mobility and transfers. R104's Care Area Assessment (CAA) for falls dated 10/22/24, was triggered due to a potential for falling due to poor muscle control and use of psychotropic meds. He 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure orders for compression were implemented for 2 of 2 residents (R40, R45) reviewed for edema. Findings include: R40's Optional State Assessment (OSA) dated 9/8/24, indicated R40 had intact cognition, did not reject cares, and required limited assistance with bed mobility, transfers, and toilet use. R40's admission Minimum Data Set (MDS) dated [DATE], indicated they had no impairment to range of motion, used a walker, and required partial to moderate assistance for showering/bathing, dressing lower body, and donning and doffing footwear. R40's Medical Diagnosis form undated indicated the following diagnoses: heart failure, difficulty in walking, cognitive communication deficit, neoplasm (tumor) of unspecified behavior of brain, malignant neoplasm of unspecified part of right bronchus or lung, secondary malignant neoplasm of brain, and metabolic encephalopathy. R40's Physician Orders form indicated the following orders; 10/11/24,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-10-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure an occupational therapy (OT) ordered hand splint program was implemented for 1 of 2 residents (R14) reviewed for positioning and mobility. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified he could understand with clear comprehension and could be understood. The cognitive assessment was not completed. Diagnoses included hemiplegia (paralysis and weakness) affecting right dominant side and muscle weakness. Extensive assistance of two staff was required for bed mobility. R14's quarterly MDS's dated 10/3/24, 8/13/24, and 5/16/24, identified no rejection of care and no days of restorative splint or brace assistance occurred. R14's activities of daily living (ADL) Care Area Assessment (CAA) dated 2/27/24, was triggered due to extensive assist of one to two staff for bed mobility, toileting, dressing, and personal hygiene, and total assist with two staff for Hoyer transfers was required. R30 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement fall interventions for 1 of 2 residents (R40) reviewed with a history of falls. Findings include: R40's admission Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition, did not reject cares, had a walker, required partial to moderate assist with toileting, showering and lower body dressing, required supervision for transfers from chair to bed, required partial to moderate assist with toilet transfers, and did not have a history of falls. R40's Medical Diagnosis form undated, indicated the following diagnoses: heart failure, muscle weakness, difficulty in walking, neoplasm of unspecified behavior of brain, malignant neoplasm of unspecified part of the right bronchus or lung, and metabolic encephalopathy (a change in how the brain works). R40's physician orders indicated the following order: • 10/11/24, apixaban (an anticoagulant) oral tablet 5 milligram (MG) give 1 tablet by mouth two times a day related 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · 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 staff utilized enhanced barrier precautions (EBP) during wound care and failed to ensure current standards of infection control practice for catheter care was followed for 1 of 2 residents (R30) observed for wound care and catheter care. Findings include: EBP R30's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition, and no behaviors or rejection of care occurred in the lookback period. Diagnoses included stress incontinence and neurogenic bladder. Currently, two unstageable pressure injuries presenting as deep tissue injury were present and R30 had an indwelling catheter. R30 required extensive assist of two staff for bed mobility, transfers, and toilet use. R30's care plan dated 9/11/24, identified EBP were in place due to foley catheter. Interventions included to follow EBP and don/doff PPE (personal protective equipment) when high contact cares were required. The care plan lacked EBP for wound…

    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 · D2024-10-24 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 conduct regular inspections of hospital bed rails as part of a regular maintenance program. Findings include: R204's admission Minimum Data Set (MDS) dated [DATE], indicated R204 had intact cognition, required partial to moderate assistance with bed mobility, was always incontinent of bowel and bladder, required substantial assistance with dressing, did not have an impairment in range of motion to upper extremities, and did not use bed rails. R204's Medical Diagnosis form undated, indicated the following diagnoses: dementia, urinary tract infection, ulcerative pancolitis (a type of inflammatory bowel disease) with unspecified complications, diarrhea, and Alzheimer's disease. R204's physician orders dated 10/22/24, indicated R204 could have bilateral grab bars. R204's care plan dated 9/28/24, indicated R204 was at risk for falls and interventions included monitoring and documenting on safety, and remove any potential causes if possible.…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-09 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 6 residents (R25, R38, R45) observed to received medication. A total of four (4) errors out of 31 opportunities were identified resulting in a 12.9% (percent) facility' error rate. Findings include: R25's Order Summary Report, dated 10/11/23, identified R25's current physician-ordered medications and treatments. This included an order for acetaminophen 500 milligrams (mg) by mouth every six hours as needed (PRN) for pain. The order had a listed start date of 9/26/23. On 11/06/23 at 2:19 p.m., registered nurse (RN)-A prepared R25's medications at a mobile cart in the hallway by the nurses' station. R25 was standing next to the cart and, upon being asked, rated their pain an eight [out of 10]. R25 then returned to their room while RN-A continued preparing R25's medications for administration at the cart. RN-A reviewed R25's electronic Medication Administration Record (MAR) which outlined the same order…

    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 · Ecited before2023-11-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure a community-use glucometer was properly cleaned and disinfected between patient' uses for 1 of 1 resident (R45) observed to have their blood glucose checked. This had potential to affect 4 of 4 residents (R45, R41, R246, R35) who were diabetic on the same unit. In addition, the facility failed to ensure appropriate hand hygiene was completed with personal cares for 1 of 2 residents (R246) whose cares were observed. Findings include: GLUCOMETER CLEANING: On 11/8/23 at 7:47 a.m., medication administration was observed with registered nurse (RN)-A present. RN-A removed a black-colored, zip-style (closed) bag from the medication cart and placed it on top of the cart before preparing R45's oral pills. When finished, RN-A picked up the zipped bag from the cart along with R45's prepared oral pills and brought them to her room. Inside the room, RN-A opened the zipped bag and removed an Assure Platinum glucometer from it. RN-A retrieved and donned a pair of gloves from the bathroom, and inserted a new strip…

    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 · Dcited before2023-11-09 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 1 of 1 residents (R3) were comprehensively assess for safety and ability who were observed to self-administer medications. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was cognitively intact, required set-up assistance for eating and oral hygiene, had complaints of difficulty or pain with swallowing, and had diagnoses of diabetes, seizure disorder, and traumatic brain injury. R3's care plan indicated she had difficulty swallowing and must sit up when drinking or eating anything, no matter how small the amount per speech therapy recommendations. R3's Upper GI (gastrointestinal) Endoscopy note dated 10/25/23, indicated she had an esophageal dilation procedure to widen two severely narrowed areas in her esophagus, and was to return for a second procedure in one to two weeks. R3's record lacked evidence of a second procedure. R3's Order Review History Report dated 11/9/23, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to provide hygienic nail care to 2 of 3 residents (R35 and R19) reviewed for dependent activities of daily living (ALD's). R19's annual Minimum Data Set (MDS) assessment dated [DATE], included R19 was severely cognitively impaired, had diagnoses of dementia and aphasia (difficulty speaking), and no behavioral concerns. R19's Cognitive Loss/Dementia Care Area assessment dated [DATE], included he required assistance with ADLs. R19's ADL Functional/Rehabilitation Potential was not assessed or triggered. R19's ADL care plan dated 4/20/20, indicated he often used his hands to eat and required set-up and encouragement for personal hygiene, but lacked nail care assistance needs. His behavioral focus dated 4/1/22, included R19 had behaviors of putting fecal matter on his plates/trays at mealtimes. A note from the Associated Clinic of Psychology dated 8/23/23, instructed staff to continue to monitor for signs that he is smearing or digging [feces],…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to schedule a follow-up gastrointestinal procedure for 1 of 1 residents (R3) reviewed who had difficulty swallowing. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was cognitively intact, required set-up assistance for eating and oral hygiene, had complaints of difficulty or pain with swallowing, and had diagnoses of diabetes, seizure disorder, and traumatic brain injury. R3's care plan dated 10/10/23, indicated she had difficulty swallowing and must sit up when drinking or eating anything, no matter how small the amount per speech therapy recommendations. R3's hospital Upper GI (gastrointestinal) Endoscopy (a procedure used to visually examine the upper digestive system with the help of a tiny camera on the end of a long, flexible tube) note dated 10/25/23, indicated she had an esophageal dilation procedure to widen two severely narrowed areas in her esophagus, and included an order to Repeat upper endoscopy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed implement care planned fall interventions, perform a comprehensive post-fall root cause analysis, and initiate and implement subsequent fall interventions for 1 of 4 residents (R4) reviewed for falls. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, had lower extremity impairment on one side, and used a wheelchair for mobility. R4 had diagnoses of fracture, depression, and schizophrenia, took antipsychotic, antidepressant, opioid, and hypoglycemic medications, was occasionally incontinent of bladder and frequently incontinent of bowel, and not on a toileting program. R4's Falls Care Area assessment dated [DATE], indicated R4 was at risk for falls due to balance problems. R4 was only able to stabilize with staff assistance when moving from seated to standing position and on and off toilet and was admitted with a history of falling. R4's ADL (activities of daily living)/Functional…

    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 · D2023-11-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure stock medications (i.e., medication used for multiple patients) were tracked and re-ordered timely to prevent disruption in supply and potential complication for 1 of 1 resident (R38) observed to need medications which weren't available. Findings include: R38's Order Summary Report, dated 10/11/23, identified R38's current physician-ordered medications and treatments. This included an order for, Sennalax-S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) . 1 tablet by mouth two times a day, with a listed start date of 9/15/23. On 11/06/23 at 7:42 p.m., licensed practical nurse (LPN)-A prepared R38's medications at a mobile cart in the hallway using R25's electronic Medication Administration Record (MAR) which outlined the same order for Sennalax-S as listed on R38's Order Summary Report (dated 10/11/23). However, LPN-A removed an opened bottle of Senna (labeled sennosides only) from the cart, placed one brown-colored tablet into the cup with R38's other medications, and attempted to administer 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, related to psychotropic (i.e., antipsychotic) medication use for 2 of 5 residents (R29, R4); and failed to ensure as-needed (i.e., PRN) antipsychotic medication use was limited or re-evaluated after 14 days for 1 of 5 residents (R19) reviewed for unnecessary medication use. Findings include: SIDE EFFECT MONITORING: A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension [which can] lead to dizziness, syncope, falls. It should be evaluated by both historical and routine measurement. R29's admission Minimum Data Set (MDS), dated [DATE], identified R29 had intact cognition 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · 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

    Based on observation, interview, and document review, the facility failed to ensure a fast-acting insulin Flexpen and newly attached needle was primed and administered in accordance with manufacturer instructions to facilitate complete dosing of the medication for 1 of 1 resident (R45) observed to receive insulin. This had potential to modify the dose of insulin being delivered and constituted a significant medication error. Findings include: R45's Interagency Physician Discharge Orders/Instructions, dated 10/30/23, identified R45 had been hospitalized for several medical conditions, including diabetes mellitus, and was being discharged to the nursing home. The orders directed to monitor R45's blood glucose three times a day prior to meals, along with other numerous medication orders including Lispro insulin (i.e., Humalog) one to five units subcutaneous three times a day per sliding scale. R45's Blood Sugar Summary, printed 11/9/23, identified R45's collected blood sugars since admission to the nursing home (11/2/23). R45's blood glucose was collected three times daily and ranged…

    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 · D2023-11-09 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 orders to obtain and process urinary analysis' and cultures (UA/UC) were acted upon, collected, and transported to the offsite laboratory for processing in a timely manner to reduce the risk of complication (i.e., worsening infection) for 2 of 2 residents (R11, R3) reviewed who had signs of potential urinary-based infections. Findings include: R11's admission Minimum Data Set (MDS), dated [DATE], identified R11 had intact cognition and was frequently incontinent of urine. Further, the MDS outlined R11 had several medical conditions including dementia and anemia, however, R11 did not have a current or previous (within 30 days) urinary tract infection (UTI). R11's care plan, dated 10/18/23, identified R11 had an alteration in elimination and mobility. The care plan listed several goals for R11's care including, Resident will be free from signs/symptoms of UTI, along with interventions to help meet these goals including assistance with toileting,…

    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 · D2023-11-09 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each 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 ensure dental needs were comprehensively assessed and, if needed, coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 2 of 2 residents (R29, R24) reviewed for dental care and services. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], identified R29 had intact cognition and no dental issues (i.e., broken teeth, missing teeth). On 11/6/23 at 4:30 p.m., R29 was observed laying in bed while in her room. R29 was interviewed and expressed she had never been asked about her dental care or needs (i.e., appointments) since she admitted to the nursing home several months' prior. R29 stated she had some missing teeth in the back of her mouth which she attributed to osteoporosis causing them to fall out. R29 stated she would like to see a dentist as her teeth, in general, were not in the best shape but reiterated nobody had addressed it with her since she…

    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 · D2023-11-09 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a therapeutic diet of thickened liquids was followed and implemented for 1 of 1 resident (R21) reviewed for therapeutic diets. Findings include: R21's face sheet dated 8/24/21, included diagnoses of chronic obstructive pulmonary disease (COPD), non-dominant sided weakness and paralysis following a stroke, difficulty swallowing following a stroke, and generalized muscle weakness. R21's care plan last reviewed 7/26/23 and initiated on 5/4/23, included a swallowing problem after a stroke, with a goal of not having injury related to aspiration through the review date (12/27/23). The intervention initiated 7/15/2022, was to monitor, document, and report as needed any signs or symptoms of difficulty swallowing, refusing to eat, or appearing concerned during meals. R21's quarterly minimum data set (MDS) dated [DATE], indicated intact cognition, supervised eating, and mechanically altered diet. The functional status portion of the MDS…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-11-09 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview and document review, the facility failed to assure that the kitchen dishwasher was maintained per the manufacturer's instructions, causing buildup of thick white residue on the outside of the machine. The had the potential to affect all 44 residents within the facility reviewed for essential equipment being maintained in a safe and operating condition. Findings include: During observation on 11/6/23, at 11:57 a.m., the kitchen dishwasher, which was a [NAME] single tray door type commercial dishwasher, had 80% of the top covered in white and yellow peeked residue, the bottom of the inside and sprayer was 100% covered in white residue and 40% of the front legs was covered in a thick, bumpy, and raised residue. During an interview with the Culinary Director (CD), on 11/7/23, at 11:28 a.m., stated that he did not know the recommended maintenance or cleaning schedule for the dishwasher. CD stated that EcoLab comes to the facility and assesses the dishwasher, and it is the facilities…

    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.

    Environmental 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

$144,586 in federal fines across 13 penalties.

  • $76,140 — penalty dated 2025-11-20
  • $17,989 — penalty dated 2024-10-24
  • $4,587 — penalty dated 2023-10-30
  • $4,587 — penalty dated 2023-10-23
  • $4,587 — penalty dated 2023-10-17
  • $4,587 — penalty dated 2023-10-10
  • $4,587 — penalty dated 2023-10-02
  • $4,587 — penalty dated 2023-09-25
  • $4,587 — penalty dated 2023-09-18
  • $4,587 — penalty dated 2023-09-11
  • $4,587 — penalty dated 2023-09-05
  • $4,587 — penalty dated 2023-08-28
  • $4,587 — penalty dated 2023-08-21

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 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 53.0+1.0 vs chain
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 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 5River Valley Health And Rehabilitation Center LLCRedwood Falls, 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 INTEREST16%since 01/01/2023
SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST32%since 01/01/2023
WBS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST26%since 01/01/2023
YAZOMA HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST26%since 01/01/2023
HALPERT, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL32%since 01/01/2023
JAFFA, NOAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR16%since 01/01/2023
LEGUM, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE26%since 01/01/2023
STERN, WILLIAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER26%since 01/01/2023
MONARCH HEALTHCARE OPERATING XII LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023

CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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
-17.1%
Operating marginrevenue minus expenses
$546K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 5%Other / private 38%

This home reported $546K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$401per resident / day
operating cost
$12,178per month
≈ monthly operating cost
$342per 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 245083. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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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