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Lyngblomsten Care Center

1415 Almond Avenue, Saint Paul, MN 55108 · Non profit - Church related · 225 certified beds · (651) 646-2941 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Jun 20252 immediate-jeopardy citations$101,482 in federal fines
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 (5/5)
  • lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $101,482 in federal fines (most recent 2024-08-29)
  • 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
1021 Bandana Blvd E · (651) 241-9700 · Call to confirm hours
Pharmacy
1583 Hamline Ave N · (651) 646-9645 · Call to confirm hours
Grocery
Park
Midway Pkwy · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 increased19.5%18.2%15.4%worse
Long-stay residents who lose too much weight1.4%4.1%5.4%better
Long-stay residents with a catheter left in their bladder1.2%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.7%2.6%2.0%better
Long-stay residents with depressive symptoms4.4%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%4.0%3.3%better
Long-stay residents whose ability to walk worsened24.5%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.7%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers4.9%5.2%4.7%typical
Long-stay residents with worsening bladder/bowel control24.2%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.5%17.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.6%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine98.4%82.7%79.4%better
Short-stay residents rehospitalized after admission27.6%23.5%22.6%worse
Short-stay residents with an outpatient ER visit8.6%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.761.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.681.901.80better

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.

56.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.7%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
71.0%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 71.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 107 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.7%CMS range 50.6–62.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.8–15.010.7%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 discharge71.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.2–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

0.88
RN hours/ resident / day
0.43
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
0.66
RN hoursweekends
16.7%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 225 beds and averages 200.9 residents a day — about 89% occupied, or roughly 24 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.43 hrs/resident/day on weekends vs 3.93 on weekdays — 13% thinner on weekends. RN hours go from 0.98 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-06-05)
4
at the previous standard inspection (2024-03-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · J2024-08-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 Physician Order for Life Sustaining Treatment (POLST) accurately reflected current resuscitation wishes for 2 of 4 residents (R1, R4) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R4 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R1's POLST dated [DATE] indicated full code status with comfort cares contrary to R1's wishes for do not resuscitate (DNR) status with comfort cares. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:25 p.m. The IJ was removed on [DATE] at 4:33 p.m. when the facility had implemented corrective action, however; non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R1's admission Minimum Data Set (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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-05-21 · 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 record review the facility failed to complete a safe transfer assessment for the use of sit-to-stand mechanical lift and follow manufacturer instructions and maintenance of the lift for 1 of 1 resident (R1) which resulted in a fall from the lift with a fracture. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when R1 became tired and weak from standing in the lift while staff changed out two batteries and were unaware of the emergency lowering features which resulted in R1 letting go sustaining left arm fracture and left wrist tendon tear. The Administrator and director of nursing (DON) were notified of the IJ on [DATE] at 5:24 p.m. The IJ was removed on [DATE] after it could be verified that the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnoses…

    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 · D2025-06-05 · 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 of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 1 of 3 residents (R13) reviewed for medication administration. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition and diagnoses of Alzheimer's disease (a progressive neurological disorder affecting a person's memory, thinking, and behavior), heart failure and anxiety. The MDS indicated R13 required partial to moderate assistance for oral hygiene and substantial to maximum assistance for personal hygiene cares. R13's self-administration of medication assessment dated [DATE] indicated R13 did not wish to self-administer her medications. R13's undated order summary report included the following orders: - Resident is not capable of safely self-administering medications, dated 10/31/23. - Albuterol Sulfate Inhalation Nebulization Solution…

    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 · D2025-06-05 · 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

    Based on observation, interview and document review, the facility failed to ensure freedom of movement was not restricted for 1 of 1 resident (R143) who was reviewed for physical restraints. Findings include: R143's quarterly Minimum Data Set (MDS) assessment, dated 4/16/25, identified severely impaired cognition. R143's diagnoses included; Parkinson's disease (a chronic progressive neurological disorder), dementia, and progressive neurological conditions accompanied by a psychotic disorder. R143 required maximum assistance to ambulate ten feet and was fully dependent on others when using the wheelchair. They also needed maximal assistance for transfers, including rolling from side to side, seating, and positioning in bed. A bed alarm was used daily. R143's care plan reviewed on 4/10/25, identified interventions for self care deficits, fall risk, and mood enhancement. The interventions included placing the resident in the common area recliner to engage in activities-such as watching the news-and for staff to observe and intervene when R143 attempted to self transfer. Staff were…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect discharge status for 1 of 1 resident (R200) reviewed for hospitalization. Findings include: R200's discharge Minimum Data Set (MDS) dated [DATE], indicated R200 admitted to facility on 2/10/25, from a Short-Term General Hospital, and discharged from facility on 3/6/25, discharging to Short-Term General Hospital. R200's progress note dated 3/5/25 at 10:00 a.m., indicted R200 discharge home back to [name of assisted living] signed onto hospice so no home services. R200's nursing progress note dated 3/6/25 at 11:04 a.m., indicated R200 discharged to [name of assisted living]. On 6/4/25 at 10:05 a.m., registered nurse (RN)-F, know as a MDS coordinator reviewed R200's MDS dated [DATE], and confirmed the MDS was inaccurately coded and R200 discharged home and not to the hospital. RN-F stated the MDS was expected coded correctly and correction would need to be completed. On 6/4/25 at 2:49…

    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 · D2025-06-05 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 consistently utilize a communication device or provide an interpreter for 1 of 1 resident (176) reviewed who was deaf and used ASL to communicate care needs. Findings Include: R176's significant change Minimum Data Set (MDS) assessment dated [DATE], identified no cognitive impairment, primary language was American sign language (ASL), and an interpreter was needed to communicate with doctors and health care staff. R176's care plan revised on 12/3/24, identified impaired communication. R176's care plan identified methods for communicating such as short, direct simple phrases, visual aids, and indicated please provide me with an ASL interpreter for all significant meetings/interactions such as care conferences, cognitive/mood assessments, etc. R176's active provider orders last reviewed 5/5/25, indicated weekly pain and skin assessments, daily ambulation program and a fluid restriction order which could have required staff to communicate…

    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 · D2025-06-05 · 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 individualized activities were provided for 2 of 4 residents (R88 and R143) reviewed for activities. Findings include: R88's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R88 was admitted to the facility 2/1/25, severe cognitive impairment, sometimes feel lonely or isolated from those around, no rejection of care, wandering occurred four to six days, but less than daily, utilized a walker and wheelchair, required substantial/maximal assistance with dressing, supervision with personal hygiene, sit to lying, sit to stand, and walking, and diagnoses included hip fracture and non-Alzheimer's dementia. R88's care plan printed 6/3/25, indicated R88's leisure interests include going to church, listening to music, talking with others and watching TV and interventions included document attendance/refusals, encourage to tell staff of leisure needs, encourage short durations of activities as able, monitor activity…

    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 before2025-06-05 · 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 comprehensively assess transfers with a mechanical lift or develop and implement policies to ensure the safety and supervision for 1 of 4 residents (R20) reviewed for accidents. Findings include: R20's annual Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition and had limited function to the right arm and hand, used a wheelchair, required maximal assistance for mobility and was on hospice. R20's diagnoses included cerebral palsy, seizure and psychotic disorders, and post-polio syndrome. R20's care plan (CP) created on 6/2/23, identified mobility as an area of concern and indicated one staff assisted with bed mobility, repositioning, and sitting up. Furthermore, the CP identified R20 had a history of compression fractures to the spine and spasticity/hemiparesis of the right hand since birth, was not ambulatory and needed one to two staff for transfers with the mechanical lift (EZ Stand). R20'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (R115) reviewed for medication administration. Findings include: R115's face sheet printed 6/5/25, indicated diagnoses of reduced mobility, cardiac pacemaker, personal history of sudden cardiac arrest, Alzheimer's disease, and heart failure. R115's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, use of wheelchair, substantial/maximal assistance with personal hygiene, lower body dressing, and bathing. R115's care plan printed revised 8/14/24, indicated self-care deficit related to congestive heart failure, pacemaker in left chest, and dementia. Staff crush my pills, mix together in applesauce to aide in swallowing. R115's physician's orders printed 6/5/25, indicated an order for metoprolol succinate extended release 50mg tablet (blood pressure medication) daily for high blood pressure. An additional 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 · Fcited before2024-03-14 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 212 residents who resided in the facility. Findings include: During an interview on 3/14/24 at 8:07 a.m., the director of physical plant (DPP)-A, stated he was responsible for the water management program, however was unfamiliar with regulations for a water management program which would prevent growth of Legionella and other waterborne pathogens. DDP-A explained the actions he took related to a water management program which included measuring water temperatures at various sites within the facility and annual testing for Legionella. DDP-A was not aware of additional requirements including completion of a Legionella risk assessment, creating a detailed diagram of the facility water system and following nationally accepted standards for a water management program.…

    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 · D2024-03-14 · 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 routine shaving for 1 of 1 resident (R36) reviewed for activities of daily living (ADL) who was dependent on staff for cares. Findings include: R36's face sheet printed 3/14/23, indicated R36 had diagnoses including heart failure (progressive disease that affects pumping action of heart muscle), morbid obesity, arthritis, and respiratory failure (serious condition that affects breathing and oxygen levels). R36's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R36 had intact cognition, no care refusal behaviors, and requires partial to moderate assist with personal hygiene. R36's care plan dated 6/28/23, indicated R36 had a self care deficit and will be clean and well groomed through the review period. The care plan indicated R36 required assist of one as needed with dressing, grooming and bathing. The care plan did not include shaving. R36's resident care sheet indicated shaving as needed. R36's task list…

    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 · D2024-03-14 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to make a follow-up appointment for 1 of 2 residents(R54) reviewed for vision. Findings include: R54's face sheet printed 3/14/24, indicated admission date of 11/8/22 and included diagnoses of diabetes mellitus type 2, end stage kidney disease, bilateral below the knee amputations, and cataract (clouding of lens of the eye that affects vision) extraction bilateral. R54's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had intact cognition, was dependent on staff for toileting, and required partial to moderate assist with personal hygiene, and transfers and rolling required substantial to maximum assistance. The MDS also indicated adequate vision, and no corrective lenses. R54's care plan printed 3/14/24, did not include a visual impairment. During interview on 3/11/24 at 6:11 p.m., R54 indicated she has asked more than once to see an eye doctor over the past year. R54 stated she feels like she is losing her vision and it is blurry…

    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 8 citations
  • Potential for harm · D2024-03-14 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to have ongoing communication and collaboration with dialysis facility for 1 of 2 residents (R54) reviewed for dialysis care. Findings include: R54's facesheet printed on 3/14/24, included diagnoses of dependence on renal dialysis (a treatment for failing kidneys to remove fluid and waste from the blood), diabetes mellitus type two, acquired absence of right and left leg below the knee, and dementia. R54's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R54 was cognitively intact, had clear speech, was understood and able to understand. R54 did not walk, uses a wheelchair and has bilateral prosthesis. R54 required partial to moderate assist with activities of daily living, and was totally dependent for transfers. R54 was receiving dialysis. R54's care plan dated 12/7/23, indicated R54 has an alteration in renal function. Interventions included: administer medications as ordered; check access site for bruit (whooshing sound…

    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 · F2023-02-16 · 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

    Based on observation, interview, and document review, the facility failed to label, date opened containers of food stored, ensure expired food were identified and removed from walk-in produce refrigerator and dry good storage room. Furthermore, the facility failed to ensure food was served under sanitary conditions, proper sanitization of thermometer when temping foods; and failed to ensure dishes and food preparation equipment were appropriately air dried. This had the potential to affect all 211 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on 2/13/22 at 2:10 p.m., with certified dietary manager (CDM)-A, observed food items in the walk-in produce refrigerator and dry goods room that were not dated or marked and/or were expired. CDM-A indicated food production manager (FPM)-B typically went through all food inventory twice weekly, checking food for opened dates and expiration dates, removing food when expired. CDM-A stated all kitchen staff should be checking food for opened dates and expiration…

    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 · Fcited before2023-02-16 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19, when during a Covid-19 outbreak and high Covid-19 community transmission, residents, visitors and staff were observed not wearing appropriate personal protective equipment (PPE), specifically masks. This had the potential to affect all 211 residents who resided in the facility. Findings include: The facility was in outbreak status when R307, who was admitted on [DATE], tested positive for Covid-19 on 2/7/23, and was in transmission based precautions. In addition, the county community transmission level for Covid-19 was high. During an observation on 2/13/23, at 3:30 p.m., observed two signs at the main entrance of the facility regarding visitor masking. Neither signs were on the door as individuals entered the facility. Both signs were laying flat, one on a credenza inside the main entrance and one…

    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 · D2023-02-16 · 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 immediately report to the administrator and no later than 2 hours, to the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident verbal abuse and an allegation of resident to resident abuse for 2 of 2 residents (R27, R192) who was reviewed for allegations of abuse. Findings include: R27's diagnoses report printed on 2/15/23, included dementia, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cardiovascular disease affecting his right dominant side. R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 was cognitively intact, had adequate vision and hearing, clear speech, was understood and could understand. R27 required extensive assistance of one staff for most ADL's (activities of daily living) and did not walk. R27's care plan created on 8/12/22, indicated R27 had an alteration in…

    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 · D2023-02-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to complete a thorough investigation for a resident to resident altercation and to assure residents were safe and prevent further potential abuse by allowing the alleged perpetrator (AP) to continue to have access to other vulnerable adults following an allegation of abuse, for 2 of 2 residents (R162, R169) investigated for abuse. Findings include: R27's diagnoses report printed on 2/15/23, included dementia, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cardiovascular disease affecting his right dominant side. R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 was cognitively intact, had adequate vision and hearing, clear speech, was understood and could understand. R27 required extensive assistance of one staff for most ADL's (activities of daily living) and did not walk. R27's care plan created on 8/12/22, indicated R27 had an alteration…

    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 · D2023-02-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interview, the facility failed to develop a comprehensive person-centered care plan which included care for an indwelling Foley catheter for 1 of 2 resident (R199) reviewed for catheter care. Findings include: R199's facility admission record dated 12/26/23, indicated R199 was admitted on [DATE], with diagnosis which included sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), and bacteremia (bacteria in the blood). admission record further indicated R199 had an indwelling Foley catheter related to urinary retention. R199's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R199 was cognitively intact and had an indwelling Foley catheter. Care Area Assessment (CAA) dated 1/12/23, indicated R199 had an indwelling Foley catheter related to urinary retention. R199's care plan dated 1/5/23, lacked mention of an indwelling Foley catheter and lacked interventions to care for an indwelling Foley catheter. When interviewed on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to provide routine catheter hygiene care for 1 of 2 residents (R138), reviewed for catheter care; who had an indwelling catheter, was at risk for infection, and had a history of urinary tract infections (UTIs). Findings include: R138's face sheet, printed on 2/16/23, indicated R138 was admitted to facility on 10/31/22. R138's diagnosis report, printed on 2/16/23, consisted of infection and inflammatory reaction due to indwelling urethral catheter, urinary tract infection, mild cognitive impairment, benign prostatic hyperplasia ((BPH)-prostate enlargement), retention of urine, and chronic kidney disease (CKD). R138's significant change minimum data set (MDS) assessment, dated 12/21/22, identified R138 having intact cognition, required assist of 1 staff for toileting and personal hygiene, had an indwelling catheter and a diagnosis of urinary retention. R138's physician order summary report, printed on 2/16/23, indicated foley catheter change every month every evening shift starting on the 3rd and ending on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-05 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 complaint investigation survey results were readily accessible and available for review within the campus. This had potential to affect all 207 residents, visitors, and their families who could wish to review the information. Findings Include: During the recertification survey on 6/2/25 at 12:21 p.m., a binder labeled survey results hung on the wall to the left of the information board located in a hallway on the 1st floor, adjacent to the front desk and contained the following results: Recertification survey dated 3/14/24 Abbreviated complaint survey results dated 5/21/24. The facility binder lacked documentation in the form of a CMS 2567 (Formal investigation documentation required by the Centers for Medicare and Medicaid Services-CMS) for investigations or standard surveys completed during the following dates: 6/27/24, abbreviated complaint survey results, 7/29/24, abbreviated complaint survey results, 8/29/24, abbreviated complaint survey results with F578- cited at J. 1/17/25, standard…

    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

“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

$101,482 in federal fines across 2 penalties.

  • $86,775 — penalty dated 2024-08-29
  • $14,707 — penalty dated 2024-05-21

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.

Who owns this facility

Owner / managerTypeRoleSince
BRANDT, JOANIndividualCORPORATE DIRECTORsince 01/01/2024
BRYANT, JUSTINIndividualCORPORATE DIRECTORsince 01/01/2024
GEORGE, DEBRAIndividualCORPORATE DIRECTORsince 01/01/2024
HAUCK, MARYIndividualCORPORATE DIRECTORsince 01/01/2024
HEINECKE, JEFFREYIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 01/01/2024
KNUDSON, MARKIndividualCORPORATE DIRECTORsince 01/01/2024
KORZENOWSKI, AMYIndividualCORPORATE DIRECTORsince 01/01/2024
LOVETT, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
MCDONALD COLTVET, JOYIndividualCORPORATE DIRECTORsince 01/01/2024
OLSEN, BRUCEIndividualCORPORATE DIRECTORsince 01/01/2024
PECK, JOHNIndividualCORPORATE DIRECTORsince 01/01/2024
POLGA, PETERIndividualCORPORATE DIRECTORsince 01/01/2024
ROCKSTAD, DIANAIndividualCORPORATE DIRECTORsince 01/01/2024
FLIFLET, TODDIndividualCORPORATE OFFICERsince 06/01/2024
ANDERSON, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
AUGER, TAYLORIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/12/2016
DAVINI, NICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2025
GERLEMAN, TRISHAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/07/2004
HART, LINDSEYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/24/2021
KAYIRANGIRWA, REDEMPTAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/12/2010
LEE, KIMBERLYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/24/2016
MAKIENEN, RAQUELLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/14/2022
MARTIN, ALLISONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/19/2021
ROGERS, KRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/26/2010
TRONDSON, CANDACEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/03/2006
WAINMAN, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/12/2014
WALSH, ILLALYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/23/2017
LYNGBLOMSTEN CARE CENTER, INC.OrganizationADP OF THE SNFsince 01/01/1966

CMS files one row per role, so the 32 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$34.5M
Net patient revenuemost recent cost report
-3.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 54%Medicare 5%Other / private 41%

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

$462per resident / day
operating cost
$14,037per month
≈ monthly operating cost
$448per 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 245347. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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