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Little Sisters Of The Poor

330 Exchange Street South, Saint Paul, MN 55102 · Non profit - Corporation · 73 certified beds · (651) 227-0336 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 2024Behavioral-health or dementia-care citation — no harm found (F0744)1 immediate-jeopardy citation$13,265 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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 $13,265 in federal fines (most recent 2024-10-03)
  • 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
360 Sherman St Ste 150 · (612) 254-7123 · Call to confirm hours
Pharmacy
280 Smith Ave N 120 · (651) 241-6380 · Call to confirm hours
Grocery
633 7th St W · (651) 224-3365 · Call to confirm hours
Park
217 Chestnut St · Typically dawn to dusk
Place of worship
330 Exchange St S · (651) 227-0336

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 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 increased15.9%18.2%15.4%typical
Long-stay residents who lose too much weight1.0%4.1%5.4%better
Long-stay residents with a catheter left in their bladder2.4%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.4%2.6%2.0%worse
Long-stay residents with depressive symptoms0.0%4.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%4.0%3.3%better
Long-stay residents whose ability to walk worsened16.6%20.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication0.0%12.5%18.9%check this — see note marked star below the table
Long-stay residents given the seasonal flu vaccine97.3%96.1%95.3%typical
Long-stay residents with pressure ulcers0.7%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control17.9%24.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.5%17.1%17.1%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

0.15U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.74
RN hours/ resident / day
0.93
LPN hours/ resident / day
3.28
Aide hours/ resident / day
4.95
Total nurse hours/ resident / day
0.55
RN hoursweekends
47.9%
Total nursing turnover
81.8%
RN turnover

How full it usually is: this home is certified for 73 beds and averages 35.6 residents a day — about 49% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.63 hrs/resident/day on weekends vs 5.08 on weekdays — 9% thinner on weekends. RN hours go from 0.82 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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

3
deficiencies at the latest standard inspection (2026-01-28)
6
at the previous standard inspection (2024-12-11)

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-03 · 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 identify, comprehensively assess, implement individualized interventions for wandering, exit seeking behaviors, and elopement for 2 of 2 residents (R1, R2) who had a history of repeated exit seeking behaviors. The facility's failures resulted in immediate jeopardy (IJ) when R1 eloped from the facility, was found on a city street, and returned by a passerby. The immediate jeopardy began on 9/5/24 after R1 attempted elopement multiple times, the facility failed to complete comprehensive wandering/elopement assessments, monitoring system, and appropriate intervention resulting in R1's actual elopement on 9/21/24. The immediate jeopardy was identified on 9/26/24 and the chief executive officer and director of nursing (DON) were notified of the immediate jeopardy on 9/26/24 at 6:18 p.m. The immediate jeopardy was removed on 10/3/24 at 11:11 a.m., but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 all required discharge documentation was provided to the resident and receiving facility; and failed to ensure transfer and discharge notices were sent to the Office of the State Long-Term Care Ombudsman (OOLTC) for 1 of 1 resident (R37) reviewed for discharge.Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, independent with dressing, hygiene and mobility. There was no active discharge planning in place and medications included anticoagulants and anticonvulsants.R37's care plan dated 7/24/25, identified resident desires to transfer to assisted living when opening is available. Interventions included social services will assist in finding assisted living per doctor's orders. R37's Order Recap Report dated 1/01/25 through 1/31/26, lacked an order to discharge.R37's provider visits summaries dated 9/11/25 and 11/13/25, lacked information or orders related to discharge. R37's progress note dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · 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 ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R19) reviewed for activities of daily living (ADLs), and who was dependent on staff for her care.Findings include:R19's quarterly Minimum Data Set (MDS) dated [DATE] indicated R19 had moderate cognitive impairment, had no behaviors, and did not refuse personal cares. R19's MDS indicated she was independent with hygiene, bathing, transfers and used a rolling walker for mobility.R19's medical diagnosis report dated 1/28/26, indicated diagnoses of congestive heart disease, cerebral infarction (stroke) without residual deficits, dementia, back pain, and hypertension.R19's care plan dated 1/28/26, indicated R19 was independent with dressing and needed limited assistance of one staff member with personal and toileting hygiene. This care plan directed one staff member to assist R19 with dressing and applying shoes. R19's Kardex indicated she received…

    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 · D2026-01-28 · 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 interview and record review, the facility failed to ensure narcotic and controlled substances destruction was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft for 1 of 1 resident (R7) reviewed for fentanyl patch removal. Findings include:R7's quarterly Minimum Data Set (MDS) date 1/14/26, indicated R7 was cognitively intact, required substantial/maximal assistance with most activities of daily living (ADLs) and mobility, and experienced almost constant pain. The MDS indicated R7 was taking opioids as scheduled pain medication regimen. R7's diagnoses included Parkinson's disease (neurological disease affecting movement), respiratory failure, and chronic pain.R7's care plan dated 5/27/25, indicated R7 required pain management due to chronic pain as a result of osteoarthritis, kyphosis (condition of humpback), scoliosis (abnormal curvature of the spine), and dorsalgia (pain anywhere in the back). R7's physician orders included:-Fentanyl Transdermal Patch 72 hour 12/mcg/hr.apply 1 patch transdermal every 72 hours for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure open refrigerated items were dated and covered. Furthermore, the facility failed to ensure expired items were removed from storage. This had the potential to impact all 32 residents residing in the facility. Findings include: An observation on 12/9/24 at 11:40 a.m., the main kitchen was reviewed. A walk-in refrigerator contained an open package of Hillshire Farm sliced turkey lunchmeat. The lunchmeat was wrapped in saran wrap and had no label or date. At 11:57 a.m., the walk-in dairy refrigerator was reviewed. The refrigerator contained 4 half gallons of [NAME] 2% milk. The best by date for all 4 containers was 12/1/24. Dietary aide (DA)-A verified the expired milk and stated they should be thrown away. At 11:59 a.m., the DietaryDirector entered the refrigerator and verified the expired milk. Dietary Director stated they were aware the date was close and didn't realize it had been expired for that long. after reviewed the date…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · 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

    Based on observation, interview, and document review, the facility failed to ensure oxygen was administered according to physicians orders for 1 of 2 residents (R11) reviewed for respiratory care. Findings include: R11's Optional State Assessment (OSA) dated 10/10/24, indicated moderate cognitive impairment, did not reject cares, did not have shortness of breath, and used oxygen. R11's medical diagnoses form indicated the following diagnosis: pulmonary fibrosis (scarring and thickening of the tissue and between the air sacs in the lungs). R11's physician's orders dated 6/26/24, indicated the following order: • oxygen 1 to 6 liters per minute per nasal cannula or mask as needed for dyspnea (shortness of breath keep oxygen saturations greater than 91% and notify the physician). R11's medication administration record (MAR) and treatment administration record (TAR) dated November 2024, indicated R11 used oxygen on 11/1,24, 11/3/24, and 11/7/24. The MAR and TAR lacked information regarding R11's oxygen saturation levels. R11's MAR and TAR dated December 2024, and printed on 12/11/24,…

    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
  • Potential for harm · D2024-12-11 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess and implement individualized person centered dementia care for 1 of 2 residents (R2) reviewed for dementia care. Findings include: R2's Clinical Diagnosis form, indicated the following diagnoses: vascular dementia with agitation, age-related macular degeneration, legal blindness, other symptoms and signs involving cognitive functions and awareness, primary generalized osteoarthritis, unilateral primary osteoarthritis of the left knee, aphasia (a language disorder making it difficult to communicate), insomnia, cerebral infarction (stroke) due to embolism (blood clot), type two diabetes mellitus with polyneuropathy (a complication where peripheral nerves are damaged throughout the body), and other cerebrovascular disease (a condition that affects blood flow to the brain). R2's Annual Minimum Data Set (MDS) dated [DATE], indicated R2 had unclear speech, had short and long-term memory problems, severely impaired…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely for 2 of 5 residents (R2, R29) reviewed for unnecessary medications. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had a short-term and long-term memory problem, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnosis of non-traumatic brain dysfunction, hypertension (high blood pressure), diabetes mellitus, aphasia (a disorder that affects how you communicate), and non-Alzheimer's dementia. Further, R2 had applications of ointments and medications other than to feet, and R2 took an antipsychotic. R2's physician orders indicated the following orders: • 7/29/21, nystatin powder apply to affected areas topically as needed for moist, abdominal, groin, breast folds that become red or odorous add routine for 7 to 10 days when rash recurs and continue as needed dose after treatment completed. • 1/15/24, nystatin…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a topical antibiotic was transcribed as written and further failed to ensure the topical antibiotic was still necessary for 1 of 1 residents (R14) reviewed for antibiotic use. Findings include: R14's quarterly MDS dated [DATE], indicated R14 was cognitively intact and had diagnoses of diabetes and hidradenitis suppurativa (disease causing puss filled boils on the skin). Furthermore, R14 was on an antibiotic. R14's dermatology provider note dated [DATE], indicated R14 was seen for a skin check. The note indicated R14s hidradenitis was clear and ordered R14 to continue the clindamycin lotion (antibiotic) for 1 year. R14's active provider orders indicated on [DATE], R14 required clindamycin phosphate 1% lotion to be applied to the abdomen/groin topically for hidradenitis. R14's clindamycin order had no end date. R14's medication administration record (MAR) dated 12/2024, indicated clindamycin 1% lotion as an active order. The MAR further 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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 physician notification of an abnormal lab for 1 of 1 resident (R29) reviewed for diabetes. Findings include: R29's Optional State Assessment (OSA) dated 9/11/24, indicated intact cognition, had diabetes mellitus, and received insulin injections 7 of 7 days. R29's admission Orders form dated 3/19/24, indicated a check box, Yes R29 could use Standing House Orders. Directly under the line, May use Standing House Orders, indicated a heading, Diabetes Mellitus Standing Orders If Applicable, with check boxes for Yes, No, or N/A. None of the check boxes were marked. A form, Standing Orders for Skilled Nursing Facilities revised 2023, indicated the following standing orders for diabetes management: • Notify the provider if two BG (blood glucose) results are less than 70 or greater than 400 in a 24 hour timeframe and or change in condition; if no condition change, notify provider on the next business day. • For a BG less than 70, if patient is symptomatic, administer 6 ounces of fruit juice, milk, other high carbohydrate…

    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 · F2024-10-03 · tag F0837 — widespread
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility's governing body failed to establish and implement policies regarding the management and operation of the facility and further failed to ensure the administrator reported to and was held accountable to the governing body. This had to effect all current and future residents residing in the facility. Findings include: Policies: During a review of facility policies, the facility was unable to provide a copy of numerous requested policies which included: policy on physician visits, including frequency; policy on emergency physician care; policy on physician delegation of tasks; policy on physician delegation of dietary orders; policy on governing body; policy on communication between administrator and governing body; policy on administration accountability to governing body; policy on staff licensure verification. Policies provided after requested by surveyors dated after the survey began included: Policy Regarding the Governing Body, Administration Appointment and Accountability to the Governing Body dated 9/28/24; Policy Regarding…

    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
Show the remaining 18 citations
  • Potential for harm · F2024-10-03 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 the Facility Assessment (FA) was complete and included an evaluation of the resident population and its needs using evidence-based data driven methods, the competencies and skill sets for all personnel necessary to provide that care, information on staffing levels needed based on the resident population, a plan for maximizing recruitment and retention of direct care staff, and all contracted services required to meet resident needs. The facility further failed to ensure the FA was conducted with input from all necessary individuals. This had the potential to affect all 36 residents residing in the facility. Findings include Facility assessment dated [DATE]th, 2024 through September 30th, 2024 (after survey entered), identified Administrator-A as CEO/Administrator and governing board. Facility assessment identified director of nursing (DON) to be involved in completing the facility assessment. Dates of assessments with review by QAPI/QAA dated…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-03 · 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 document review and interview the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q3), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This had the potential to affect all 36 residents residing in the facility. Findings include Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D dated 5/1/24 through 6/30/24 (Q3), identified no triggered metrics for staffing. During interview on 10/2/24 at 2:45 p.m., Providence payroll administrator (PA), reported her job role was to submit and complete the payroll-based journal regionally for Little Sisters of the Poor. PA explained the process was for the contracted services for the sisters who were considered contracted staff to submit reportable hours worked with a sisters contracted service time sheet via email. PA would use those emails to submit time into PBJ. PA was unaware of any process in place for how time was divided between spiritual…

    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 · F2024-10-03 · tag F0940 — failed to train staff — widespread
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. This had the potential to affect all 36 residents residing at the facility who received care from facility staff, contracted staff, and volunteers. Findings include: SEE F730: Based on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-D, NA-E, NA-F and NA-G) who had been employed by the facility for over one year. SEE F947: Based on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-F, NA-G) reviewed for annual training. Additionally, 1 of 5 nursing assistants had no abuse or dementia training which had the potential to affect all 36 residents in the facility. The Facility Assessment with dates of assessment 1/29/24 to 2/1/24, included Our…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-03 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-F, NA-G) reviewed for annual training. Additionally, 1 of 5 nursing assistants had no abuse or dementia training which had the potential to affect all 36 residents in the facility. Findings include: During interview on 10/2/24 a 4:19 p.m., NA-F was unaware of how many hours of required training was provided but thought required training had been completed. Upon review of NA-F's employee file NA-F did not have 12 hours of employee training. During interview on 10/2/24 at 4:24 p.m. NA-G reported completed online Relias throughout the year. Outside of Relias training NA-G stated the director of nursing (DON) would compose a letter for all staff to sign every three to four months. NA-G reported recalled an incident which happened last year and received dementia training from signing off on a letter. Upon review of NA-G's employee file NA-G had not received 12…

    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 date of correction
  • Potential for harm · Dcited before2024-02-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report allegations of an unwitnessed fall with serious injury immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for falls. Findings include: A Facility Reported Incident (FRI) submitted to the SA on 2/5/24 at 8:34 p.m., indicated on 2/5/24 at 3:45 p.m., R1 was found on the floor in a face-down position, moaning and groaning in pain. R1 had a large amount of bright red blood all over her face a laceration wound to her forehead. R1 was unable to move her left wrist which was swollen and bruised. A nurse applied pressure to stop severe bleeding. Staff called 911, and R1 was transferred to the hospital by ambulance. R1's After Visit Summary with hospital discharge date d 2/5/24, indicated R1 sustained a traumatic head injury with multiple lacerations. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. R1's progress note dated 2/6/24 at 1:05 a.m., indicated R1…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-01 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to designate one or more individuals as the infection preventionist who would be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all 38 residents residing in the facility. Findings include: The Infection Preventionist/Staff Development Position Description form indicated the infection preventionist (IP) qualifications included a current registration with the Minnesota Board of Nursing as a registered nurse in good standing, three years nursing experience in a nursing home/geriatric setting or equivalent, prior experience in infection control responsibilities required, and a valid CDC (Centers for Disease Control) nursing home infection preventionist certification. IP-G's resignation letter dated 9/13/23, indicated IP-G's last day of employment was 10/2/23. An Indeed advertisement for the facility IP position indicated an ad was placed on 9/16/23, however under the heading, Job Status was paused. During interview on 1/31/24 at 2:39 p.m., the director of nursing (DON)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and documentation review, the facility failed to ensure hot foods are to be held at 135 degrees Fahrenheit or higher for 1 out of 3 steam tables used to serve food. This has the ability to affect 12 of 38 residents who ate food from the first floor dining room. Findings include: Resident Council meeting minutes were reviewed from 2/7/23, 10/10/23, and indicated on 2/7/23, a resident council agenda under the heading, Old Business indicated hot food being served cold and a person was invited to speak on the subject. Minutes from 10/10/23, indicated the large hot table for serving would open when there were 35 or more people served and the heating carts needed time to heat well, the kitchen must make note that the food is hot when brought out to the dining room. During interview on 1/29/24 at 3:16 p.m., R28 stated many times when eating meals from the first floor dining room, the food is cold when they received it. R28 further stated when you first walk into the main dining room area there is an area where they used to pick up their food and stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-01 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    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 a clinical shared discussion regarding pneumococcal vaccinations according to Centers for Disease Control (CDC) and have a process to assess, offer and provide the most recent CDC education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R32, R25, and R37) reviewed for immunizations. Findings include: The CDC Pneumococcal Vaccine Timing for Adults dated 3/15/23, indicated adults aged 65 years and older who have had no prior pneumococcal vaccinations could either have option A which indicated PCV20, or option B, give PCV15 and follow with PPSV23 after at least one year of giving PCV15. If only the PPSV23 vaccination was administered prior at any age, option A indicated PCV20 could be administered after 1 year or option B indicated PCV15 could be administered after 1 year. If only the PCV13 vaccination was administered at any age, option A indicated PCV20 could be administered after 1 year, or PPSV23.…

    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 before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R32) reviewed for accidents was assessed for safe use of a curling iron. Findings Include: R32's annual minimum data set (MDS) dated [DATE], indicated R32 had moderate cognitive impairment and required limited assistance with transfers and supervision when ambulating. R32's face sheet printed 2/1/23, indicated R32 diagnosis included cerebrovascular disease (an interruption in the flow of blood to cells in the brain) mild cognitive impairment, age related macular degeneration (is an eye disease that can blur your central vision. It happens when aging causes damage to the macula, the part of the eye that controls sharp, straight-ahead vision) to right and left eye. R32's care plan lacked documentation of a focus, goals, and interventions for R32's safety with curling iron use. During observation on 1/30/24 at 9:02 a.m., a black curling iron was noted in R32's room in the bathroom sink, unplugged. R32 had a private…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-01 · 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 hand hygiene was performed for 1of 2 residents (R24) observed for incontinent cares and failed to ensure a Hoyer lift was cleaned between resident use for 2 of 2 residents (R18, and R24), observed for infection control practices. Findings Include: Hand Hygiene: R24's quarterly minimum data set (MDS) dated [DATE], indicated R24 was cognitively impaired, had impairment to both lower extremity and was dependent on staff for toileting hygiene, transfers and was incontinent of bowel and bladder. R24's face sheet printed 2/1/24, indicated diagnosis of dementia and osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time) of the left knee. R24's care plan updated 1/29/24, indicated R24 required total assist of two staff with Hoyer lift transfer, was unable to stand and was non-weight bearing. During observation on 1/30/24 at 1:12 p.m., nursing assistant (NA)-B took the Hoyer lift from near 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 · E2023-10-04 · tag F0679 — failed to provide activities — pattern
    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 provide meaningful activities for 3 of 3 residents (R1, R3, R4) who were dependent on staff for activities. Findings include: Upon observation on 10/3/23 at 9:12 R1 was seated fully dressed and groomed seated in her wheelchair outside of the nurse's stations. There was another resident seated in a wheelchair next to her. The two residents were not conversing back and forth. Upon observation on 10/3/23 at 10:59 a.m. R1 was seated outside the nursing station in her wheelchair. There were two other residents in wheelchairs outside the nurse's station. All three residents were asleep in their wheelchairs. Upon observations on 10/3/23 at 12:36 p.m. R1 was being wheeled by staff back to her room to lay down for a nap. Upon observations on 10/3/23 at 2:09 p.m. R1 was seated in her wheelchair in her room alone. R1 was facing a television that was not turned on. R1's room was quiet, and the lights were off. Upon observation on 10/3/23 at 3:13…

    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 · E2023-10-04 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    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 a qualified activities director to oversee the development, implementation, and ongoing evaluation of the activities program for the facility. Upon interview on 10/3/23 at 10:44 a.m. the assistant activities director (AD)-A stated she was hired at the facility four years ago for facility gardening. AD-A stated when there was not gardening to be done, she would assist the activities department with activities. She stated the facility had been without an activity director since 2/2023 and she has been filling in since that date. She stated she mainly spends her mornings in the garden and spends her afternoons doing activity assessments or performing an activity. AD-A stated she was not certified as an activity director, and she has not had two years' experience in a social or recreations program within the last five years, one of which was a full-time in a therapeutic activities program. She stated she is not an occupational therapist or occupation therapy assistant. When interviewed on 10/4/23 at 9:20 a.m. the human…

    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 before2023-10-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse and an injury of unknown origin to the State Agency (SA) within two hours for 2 of 2 residents (R1 and R3) reviewed for abuse. A staff reported to administration an allegation of abuse involving R1 three days after an incident, and R3 was hospitalized with two fractured ribs and a pneumothorax (air leaks into the space between the lungs and chest wall, a blunt or penetrating chest injury). Findings include: R1's care plan dated 2/12/13 R1's interventions were to offer support and reassurance. Allow R1 time to communicate needs. Staff was to speak clear and direct, address her by name to gain her attention. Staff was to stoop in front of R1 at eye level when speaking with her. R1's annual Minimum Data Set, dated [DATE], indicated R1 had unclear speech, rarely makes self-understood verbally and nonverbally, rarely understands others, highly impaired vision. R1 had short and long-term memory problems and her cognitive skills…

    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 · D2023-10-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update the plan of care for 1 of 1 resident (R3) reviewed for care plans when R3 was moved to a different floor of the facility and not allowed to her previous floor she resided on without assistance due to inappropriate affectionate behaviors. Findings include: A facility Grievance or Complaint form dated 8/17/23 indicated R3 was to be moved to a different floor related to preventing in appropriate behavior between her and another resident. R3's quarterly MDS dated [DATE] indicated R3 had clear speech, sometimes able to express ideas and wants, sometimes understands others. R3 had highly impaired vision. R3's Brief Inventory of Mental Status (BIMs) score was a two indicating severe cognitive impairment. R3 R3's pertinent diagnoses were last stage Alzheimer's disease, anxiety, and depression. R3 required extensive assistance of two staff members for bed mobility, transferring, dressing, eating, toilet use and personal hygiene. R3'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-04 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    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 required abuse, neglect, and exploitation training was completed for 2 of 4 staff, (licensed practical nurse (LPN-A and nursing assist (NA)-A) whose personnel records were reviewed. Findings include: During interview on 10/4/23 at 11:52 a.m. LPN-A stated she does not recall the last time she had abuse, neglect, and exploitation training. She stated she had retired in 2017 and came back as a casual employee, stating she was not certain if she needed annual training anymore. LPN-A stated due to a recent improvement plan at the facility she had been assigned Relias (online education) training on 9/26/23. LPN-A stated she had not completed the training due to technical issues; she did reach out to the Human Resource Department. Upon record review of personnel files, there was no documentation of training of abuse, neglect, and exploitation for LPN-A or NA-A. Upon interview on 10/4/23 at 2:34 p.m. the Human Resource Director (HR)-A stated she was certain all training was in the staff files. She stated she would look…

    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
  • No harm found · C2024-10-03 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-D, NA-E, NA-F and NA-G) who had been employed by the facility for over one year. Findings include: NA-D personnel record identified a hire date of 4/9/2007, with the last performance evaluation completed on 4/29/2020 and additional one completed in 2016. NA-E personnel record identified a hire date of 3/3/2005, with the last performance evaluation completed on 5/19/2021. NA-F- personnel record identified a hire date of 8/19/2020, with no job performance review. NA-G - personnel record identified a hire date of 04/29/201,5 with the last performance evaluation completed on 5/8/2020. During interview on 10/2/24 at 4:24 p.m., NA-G reported to have been working for the facility for 13 or 14 years. NA-G was unaware of when the last performance review completed. NA-G thought it was completed in the last year, however reported the facility has been very busy in the last three years. During a a return phone interview from 10/2/24 at 4:19 p.m., NA-F reported…

    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 date of correction
  • No harm found · C2024-10-03 · tag F0843 — widespread
    Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and document review, the facility failed to have a written transfer agreement with a hospital approved for participation under Medicare or Medicaid programs which reasonably ensured residents would be transferred to the hospital and ensured timely admission. This had the potential to affect all 36 residents in the facility who could require hospitalization on an emergency basis. Findings include: During a review of the facility's policies and procedures, a written transfer agreement was requested to demonstrate the facility had a transfer agreement in place with a Medicare and Medicaid participating hospital. During an interview on 10/1/24 at 2:45 p.m., the director of nursing (DON) stated she was unable to find a written transfer agreement with a hospital. She stated to her knowledge the facility did not have a transfer agreement and had not made a good faith effort to enter into an agreement with a hospital which was refused. Facility policy titled Hospital Transfers dated 11/10, did not address a transfer agreement with a hospital.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-02-01 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This had the potential to affect all 38 residents who resided at the facility. Findings include: The Infection Preventionist/Staff Development Position Description form indicated the infection preventionist (IP) participated in quarterly QA meetings and presented infection trends and other pertinent data. IP-G's resignation letter dated 9/13/23, indicated IP's last day of work was 10/2/23. The facility quality assurance quality improvement (QAPI) fourth quarter report dated 10/27/23, indicated a heading, Reports with various staff from the departments at the facility and a heading, Others in Attendance. The form lacked information an IP attended the meeting. The QAPI first quarter report dated 1/26/24, indicated a heading, Reports with various staff from the departments at the facility and a heading, Others in Attendance which lacked information an IP attended the meeting. The report indicated urinary tract infections 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.

    Administration 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

$13,265 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $8,021 — penalty dated 2024-10-03
  • $5,244 — penalty dated 2023-11-06
  • Medicare payment denial — starting 2024-10-30 for 9 days

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.

Who owns this facility

Owner / managerTypeRoleShareSince
KANNANGARA, DONNA MARIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF100%since 10/01/2024
DONACIK, RONALDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
SHARMA, HIMANSHUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2000

CMS files one row per role, so the 8 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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 245524. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, 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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