Shirley Chapman Sholom Home East
740 Kay Avenue, Saint Paul, MN 55102 · Non profit - Corporation · 118 certified beds · (651) 328-2008 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.9% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.2% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.2% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 8.0% | 4.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.5% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 89.9% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.4% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.5% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.3% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.5% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.03 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.90 | 1.80 | better |
‡ 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.
66.8% 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 228 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.4% 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 109 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 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 66.8%CMS range 60.5–71.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.3–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 4.0–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 118 beds and averages 91.7 residents a day — about 78% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.47 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 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 4.73 hrs/resident/day on weekends vs 5.40 on weekdays — 12% thinner on weekends. RN hours go from 1.55 to 1.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · K2023-03-30 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 residents wishes regarding code status were accurately reflected throughout medical records for 4 of 94 residents (R25, R41, R86, R349). The facility staff also lacked a consistent process on where to find the code status. This failure resulted in an immediate jeopardy (IJ) for R25, R41, R86, R349, when their medical records failed to identify the residents' wishes accurately. The IJ began on [DATE], when R25's providers order for life sustaining treatment (POLST) signed by provider indicated do not resuscitate (DNR) with selective treatment. However, the physician orders dated [DATE], indicated full code. The code status was not reflected consistently in R25, R86, R41, and R349's medical record. The IJ was identified on [DATE]. The corporate director of clinical services and the director of nursing (DON) were notified of the IJ on [DATE], at 10:58 a.m. The IJ was removed on [DATE], but noncompliance remained at the lower scope and severity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review the facility failed to ensure dietary staff was wearing beard guards/restraints when preparing food. This had the potential to affect all 93 residents who reside at the facility and consume food from the kitchen. During observation on 4/16/25 at 10:03 p.m., cook (C)-A had a beard and was preparing roast beef and slicing it on the meat slicer. C-A was not wearing a beard guard/restraint. During observation on 4/16/25 at 10:11 a.m., the culinary manager (CM) had a beard and was stiring a large vat of beef stew. Then he started taking food temperatures and putting the food into an insulated food cart. The CM was not wearing a beard guard/restraint. During interview on 4/16/25 at 10:33 p.m., the CM verified the staff with beards were not wearing beard guards and it had never been an expectation for them to do so. He further verified the facility didn't have any beard guards/restraints available to use, stating if it had been an expectation to wear one he wouldn't have a beard. During interview on 4/16/25 at 2:08 p.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the provider of the use of antibiotics concurrent with warfarin, and to obtain a new INR monitoring date for 1 of 2 residents (R76) reviewed for medication administration. Findings include: R76's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no behaviors, needed partial/moderate assistance for upper and lower body dressing, and substantial/maximal assistance with bed mobility. Diagnoses included hip and knee replacement. R76's medications included an anticoagulant. R76's care plan dated 3/18/25, identified a potential complication: bruising, bleeding, hemorrhage R/T (related to) a dx (diagnosis) of HX (history) of DVT (deep vein thrombosis a type of blood clot) m/b (manifested by) chronic anticoagulation use. Be aware of risk for drug-to-drug interactions. Inspect for signs of bleeding. PT/INR (blood clotting test which checks whether medicine to prevent blood clots is working) per order; report results to MD/NP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R48) who had dried tube feeding formula on the base of the tube feeding pole. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R48 had moderate cognitive impairment, was dependent on staff for all activities of daily living (ADL), and received 51 percent or greater daily nutrition through a feeding tube. R48's diagnoses included malnutrition, type 2 diabetes, anxiety, and major depressive disorder. R48's care plan dated 3/21/25, indicated R48 had little to no oral intake and relied on tube feeding to meet my nutrient needs. R48's physician orders indicated the following: -Formula Type: ISOSOURCE 1.5, per pump 45 ml/hour continuous gastrostomy. Start date: 11/27/24. - Wipe down pole and pump with damp cloth daily on pm shift. Start date: 10/24/24. R48's medication administration record (MAR) dated 4/1/25 through 4/15/25, indicated 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.
- Potential for harm · D2025-04-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 1 residents (R61) received treatments and services to promote the healing of a pressure ulcer per the comprehensive care plan. Findings include: The State Operations Manual (SOM) revised 2/3/23, defines a pressure ulcer as an area of damaged skin and/or underlying soft tissue normally over a bony prominence or from a device. The injury occurs due to intense or prolonged pressure, or pressure in combination with shear. Other contributing factors include skin temperature and moisture, nutrition, perfusion (the blood flow through tissue), co-morbidities and the condition of the skin and soft tissue. The SOM defines a deep tissue pressure injury (DTPI) as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mush, boggy, warmer or cooler as compared to adjacent tissue. Furthermore, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a hand brace and palm protector was used consistently for 1 of 1 resident (R71) reviewed for range of motion (ROM). Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact, had limited ROM with impairment of upper and lower extremities on one side, required substantial/maximal assistance with upper body dressing, and received zero minutes of ROM or splint/brace assistance in the 7 day lookback period. R71's diagnoses included hemiplegia and hemiparesis (weakness/paralysis affecting one side of the body) following a stroke affecting left non-dominant side, type 2 diabetes and lymphedema. R71's care plan dated 3/31/25, indicated R71 had decreased ROM to left upper extremity (LUE) and was at risk for contractures (condition where muscles or tendons become permanently shortened, causing loss of movement). R71's care plan instructed staff to DON [apply] Brace to L Arm @ [at] HS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 fully assess and follow up on weight loss and meal intakes for 1 of 2 resident (R73) reviewed for nutrition. Findings include: R73's Optional State Assessment (OSA) dated 3/17/25, indicated intact cognition, required supervision and set up support with eating. R73's admission Minimum Data Set (MDS) dated [DATE], indicated R73 had an impairment in range of motion on one side of the upper extremity, required supervision with eating, did not have a swallowing disorder, was 63 inches and weighed 146 pounds, had no or unknown weight loss or gain in the past 6 months, and had the following diagnoses: displaced comminuted fracture of the shaft of the right humerus (right arm), urinary tract infection, age related macular degeneration, other disorders of electrolyte and fluid balance, hearing loss, and history of malignant neoplasm of the large intestine. R73's Nutrition Care Area Assessment (CAA) dated 3/17/25, indicated R73 had functional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 feeding tube tubing and nutrition bag were labeled according to professional standards to avoid the possibility of feeding tube complications and or related infections for 1 of 1 residents (R48). Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R48 had moderate cognitive impairment, was dependent on staff for all activities of daily living (ADL), and received 51 percent or greater daily nutrition through a feeding tube. R48's diagnoses included malnutrition, type 2 diabetes, anxiety, and major depressive disorder. R48's care plan dated 3/21/25, indicated R48 had little to no oral intake and relied on tube feeding to meet my nutrient needs. R48's physician order dated 11/27/24, indicated, Formula Type: ISOSOURCE 1.5, per pump 45 ml/hour continuous gastrostomy. R48's medication administration record (MAR) dated 4/1/25 through 4/15/25, indicated received daily continuous tube feedings. R48'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.
- Potential for harm · D2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R23) reviewed for respiratory care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADL), and required continuous oxygen therapy. R23's diagnoses included acute respiratory failure with hypoxia (low oxygen levels in tissues), Alzheimer's disease, dementia, and congestive heart failure. R23's care plan dated 4/4/25, indicated R23's diagnoses of Acute respiratory failure but failed to provide guidance for monitoring respiratory status or oxygen therapy. R23's physician orders dated 3/20/25, indicated the following: -Discard and replace oxygen tubing weekly - Sun 11-7 shift. -Discard and replace oxygen humidifier/bubbler weekly. R23's treatment administration record (TAR) dated 4/1/25 through 4/15/25, indicated, Discard and replace oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure the recommended personal protective equipment (PPE) was utilized during high-contact cares for 2 of 3 residents (R48 and R53) reviewed for enhanced barrier precautions (EBP). Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care, dependent on staff for dressing, hygiene, bathing and rolling left to right in bed. Had an indwelling catheter, feeding tube, was at risk for pressure ulcers but had none during the lookback period. Diagnoses included malnutrition, neurogenic bladder, diabetes, and dementia. R48's care plan dated 1/30/25, identified EBP were in place due to indwelling medical devices of urinary catheter and feeding tube. Goals included remain free of infection and prevent the spread of MDROs (multidrug-resistant organisms) within the community. Approaches included sign on resident's door to alert staff and visitors of EBP. PPE per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to review and revise the care plan with current interventions for the care of a new catheter and enhanced barrier precautions (EBP) for 1 of 1 residents (R2) reviewed. Findings include: R2's physician order dated 9/10/24, indicated R1 required a foley catheter related to diagnosis of urinary retention due to neurogenic bladder. R2's progress note dated 9/10/24, indicated R2 had returned to the facility following hospitalization. R2 was admitted to the hospital for septic shock due to bacteremia (blood stream infection) caused by an infected kidney stone. R2 came back to the facility with a foley catheter. R2's care plan revised on 9/20/24, indicated R2 had an actual alteration in elimination related to impaired mobility, overactive bladder exhibited by frequently incontinent of bowel and bladder. R2 had a diagnosis of neurogenic bladder and was at risk for skin breakdown and urinary tract infection (UTI). Further, R2's care plan directed staff to offer toileting at start of shift, every two to three hours and as needed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-09-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 residents (R2) reviewed who had an indwelling catheter. In addition, the facility failed to ensure appropriate infection control measures for draining a catheter bag were implemented for 1 of 1 residents (R2) reviewed. Findings include: R2's physician order dated 9/10/24, indicated R1 required a foley catheter related to diagnosis of urinary retention due to neurogenic bladder. R2's progress note dated 9/10/24, indicated R2 had returned to the facility following hospitalization. R2 was admitted to the hospital for septic shock due to bacteremia (blood stream infection) due to infected kidney stone. R2 came back with a foley catheter. R2's care plan as of 9/25/24, lacked identification R2 had a foley catheter or that R2 was on EBP. During an observation on 9/24/24 at 3:59 p.m., nursing assistant (NA)-A and NA-B applied a surgical mask and entered R2's room. R2 was noted to be lying in bed and a catheter bag was noted to be hanging 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.
- Potential for harm · Ecited before2024-06-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure food was properly stored, labeled, and dated. Additionally, the facility failed to ensure 2 of 2 dishwashers in the [NAME] and Macalester unit met minimum wash temperature. This had potential to affect all residents, staff, and visitors who eat food from the main kitchen and use dishes from the [NAME] and Macalester unit. Findings include: LABELING, STORAGE, PREPARATION During initial observation on 6/10/24 at 12:00 p.m. and Culinary Services Manager (CSM)-K interview at 1:00 p.m., a large walk-in freezer had a large blue bag of multiple frozen meat with no label or date. CSM-K stated they were turkey breasts and verified they did not have a label or date and stated the box may have been destroyed. There was a foil tin pan labeled 11/25 and when opened there were a few knishes. CSM-K stated they would probably be thrown out as more had been made since then. Another large walk-in freezer had a pan labeled 5/8 butterscotch bars…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to ensure the least restrictive infection control measures were implemented for 1 of 1 resident (R21) reviewed for covid-19 exposure. Additionally the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R104) observed during contact precautions, failed to ensure standards of practice were followed for catheter care for 1 of 1 resident (R408) and failed to ensure proper storage of clean linen with the potential to impact 25 residents on two wings were implemented. Findings include: The Center for Disease Control (CDC) guidance dated 3/18/24, identified asymptomatic patients do not require empiric use of transmission-based precautions (TBP) while being evaluated for SARS-CoV-2 (covid-19) following close contact with someone with covid-19 infection. Examples of when empiric TBP following close contact may be considered include: - Patient is unable to be tested or wear source control as recommended for the 10 days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0554 — isolatedAllow 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 medications (SAM) assessment was completed to allow resident to safely administer their own medication for 1 of 2 residents (R101) observed with medications at bedside. Findings include: R101's admission Minimum Data Set (MDS) dated [DATE], indicated R101 was cognitively intact, hypertension, arthritis, and hip fracture. R101 required substantial and/or maximal assistance for toileting and toileting hygiene, dressing, bed mobility, and was dependent with chair/bed-to-chair transfers. R101's physician's orders did not include Tums during document review on 6/10/24. R101's SAM assessment dated [DATE], indicated R101 did not want to self-administer medications. During observation and interview on 6/10/24 at 3:05 p.m., a bottle of Tums (calcium carbonate chewable tablet) was observed on R101's bedside nightstand. The bottle was mostly empty and did not have a resident label on it. R101 stated they took the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to notify a provider for a significant weight gain for 1 of 1 resident (R104) reviewed for notification of change. Findings include: R104's admission Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and had diagnoses of heart failure, heart attack, coronary artery disease (CAD, a buildup of plaque that limits blood flow to the heart), chronic kidney disease and anxiety. R104's Care Area Assessment (CAA) for nutrition dated 6/3/24, indicated weight loss was not warranted and weight maintenance was the goal of his care. An initial nutrition assessment dated [DATE], indicated R104 received a cardiac diet with regular textures and thin liquids. The progress note indicated R104 had lost approximately 50 pounds over a year prior to his admission to the facility and his goal was weight maintenance. The nutrition assessment indicated R104 was agreeable to receiving a supplement beverage daily to promote adequate intake 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.
- Potential for harm · D2024-06-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure grooming was offered and or provided for 2 of 3 residents (R16, R8) reviewed for shaving. The facility also failed to ensure nail care was provided for 1 of 1 resident (R8) reviewed for activitiy of daily living. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not reject cares, was dependent on staff for toileting hygiene, showering, dressing and required substantial to maximal assistance with personal hygiene which included combing hair, shaving, applying makeup, washing and drying face and hands. R16's Face Sheet form dated 6/13/24, indicated the following diagnoses: type two diabetes mellitus, atrial fibrillation, chronic diastolic heart failure, morbid obesity, depression, anxiety disorder, and preglaucoma. R16's Care Area Assessment (CAA) dated 1/25/24, indicated R16 was dependent on staff for activities of daily living (ADLs) and had impaired cognition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0685 — isolatedAssist 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 observation, interview, and document review, the facility failed to provide assistance to ensure eyeglasses were available in order to maintain vision needs for 1 of 1 resident (R20) reviewed for vision. Findings include: R20's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R20 had intact cognition, had adequate vision with corrective lenses, was dependent on staff for personal hygiene. R20's Face Sheet dated 6/13/24, indicated the following diagnoses: type two diabetes mellitus, had an intraocular lens, had a corneal transplant, and primary open angle glaucoma bilateral, severe stage. R20's Care Area Assessment (CAA) dated 5/7/24, indicated vision was adequate but had glaucoma and received multiple eye drops and her last eye appointment was on 5/2/24 and was fitted with new glasses. R20 had advanced left eye glaucoma with poor vision in the left eye with central vision loss, severe stage primary open angle glaucoma. R20 had a potential for decline in vision and changes in vision would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 breakfast was provided to a resident prior to dialysis and failed to monitor food intakes for 1 of 3 residents (R20) reviewed for nutrition. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject cares, was very important to have snacks available between meals, required set up or clean up assistance with eating and oral hygiene, did not have weight loss or gain, was not on an altered diet or therapeutic diet, was 65 inches and weighed 210 pounds and had no natural teeth, took insulin, and was on dialysis. R20's Face Sheet form dated 6/13/24, indicated R20 had the following diagnoses: long term use of insulin, malignant neoplasm of vulva, secondary and unspecified malignant neoplasm of lymph node, osteoarthritis, primary open-angle glaucoma, bilateral severe stage, type two diabetes mellitus, end stage renal disease (ESRD), dependence on renal dialysis, acute on chronic diastolic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-30 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure the required nurse staff information was posted daily. This had the potential to affect all of the 94 residents residing in the facility and/or their visitors who may wish to view this information. Findings include: On 3/27/23, at 11:59 a.m. the facility's posted nursing hours for 3/23/23, were observed on a wall located on the main floor by the water fountain. On 3/28/23, at 9:00 a.m. the facility's posted nursing hours for 3/28/23, were observed on a wall located on the main floor by the water fountain. On 3/29/23, at 12:29 p.m. the facility's posted nursing hours for 3/28/23, were observed on a wall located on the main floor by the water fountain. On 3/30/23, at 9:00 a.m. the facility's posted nursing hours for 3/28/23, were observed on a wall located on the main floor by the water fountain. On 3/30/23, at 9:20 a.m. the director of nursing (DON) was interviewed and stated the daily postings are posted on a wall located on the main floor by the water fountain. DON stated it is her expectation the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-30 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct a quality deficiency identified during a previous survey related to advanced directives which resulted in a deficiency identified during this survey. This deficient practice had the potential to affect all 95 residents currently residing in the facility. Findings include: A facility quality assurance (QA) task force was developed to review the deficient practices as well as areas of concern that were identified during the survey process. Weekly meetings were scheduled to identify and review the identified areas of focus. These meetings were dated [DATE]-[DATE] and the meeting notes revealed on [DATE], an immediate jeopardy (IJ) was issued at F678 when the facility failed to provide cardiopulmonary respiration (CPR) to a resident who was found unresponsive (without pulse or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-30 · tag F0554 — isolatedAllow 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 self-administration of medication (SAM) was appropriate for 1 of 1 resident (R41) who was observed with medications at the bedside. Findings include: R41's significant change minimum data set (MDS) dated [DATE], indicated R41 was cognitively intact and required minimal assistance for most activities of daily living (ADLs). R41's diagnoses included anxiety, depression, psychotic disorder, amnesia, and diabetes. R41's care plan dated 3/22/23, indicated R41 had an alteration in self-care ability as evidenced by occasional assist with ADLs. The care plan further indicated, R41 was at risk for skin breakdown related to the use of steroid cream. R41's care plan lacked evidence for SAM. R41's physician orders start date 11/18/22, and discontinued 3/20/23, indicated triamcinolone acetonide (a steroid used to treat skin conditions) lotion; 0.1%. Apply to both LEs (lower extremities) twice a day for pruritis (itchy skin). R41's orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 2 of 2 residents (R68,R86). Findings include: R68's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and diagnoses of unspecified dementia, history of falling, and required extensive assist for most activities of daily living (ADLs). The MDS further identified physical restraints were not used. R68's active physician orders in the electronic medical record (EMR) were reviewed and lacked orders for any restraints. R68's care plan dated 3/8/23, indicated R68 required assist of one to two staff to assist with bed mobility. R68's care plan dated 3/16/23, indicated risk for falling due to a history of falls, impaired mobility, and poor safety awareness with an intervention, Bedroom furniture rearranged, bed moved against the wall, opposite side the resident prefers to exit/enter bed. R68's Event Report dated 2/9/23, in the EMR indicated an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and 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 interview and document review, the facility failed to develop and implement an effective discharge planning process which included resident and/or responsible party for 1 of 1 (R86) reviewed for discharge planning process. Findings Include: R86's admission Record identified admission on [DATE]. R86's Minimum Data Set (MDS), dated [DATE], indicated R86 has severe cognitive impairment and was diagnosed with Alzheimer's disease, dysphagia (difficulty swallowing), intracranial injury (brain injury), right sided weakness in upper and lower extremity, and required extensive assist for most activities of daily living (ADLs). Social services progress note on 2/21/23, recorded as late entry on 2/23/23, at 12:40 p.m. stated writer met with resident's daughter regarding his need for long term care (LTC) following therapy. We discussed that our LTC can't accommodate him due to the level of care he needs. Family understands and would like him to continue receiving part-B therapy as long as possible as he is making…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-30 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 adaptive equipment to promote independence with eating and drinking for 1 of 1 resident (R86) who was reviewed for nutrition and observed having difficulty eating and drinking. Findings Include: R86's Minimum Data Set (MDS) dated [DATE], indicated R86 has severe cognitive impairment and was diagnosed with Alzheimer's disease, dysphagia (difficulty swallowing), intracranial injury (brain injury), right sided weakness in upper and lower extremity, and required extensive assist for most activities of daily living (ADLs) including feeding assistance. R86's care plan updated on 1/18/23, indicated per occupational therapy (OT) plate guard, hard plastic cup, built up utensils, and dycem (non-slip material) under plate for all meals to increase independence with self-feeding and required feeding assistance at meals. R86's OT Evaluation and Plan of Treatment dated, 1/4/23, indicated patient will safely perform self-feeding tasks with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure current standards of practice for catheter care was followed for 1 of 1 resident (R68). R68's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and diagnoses of unspecified dementia, urinary tract infection, had an indwelling urinary catheter, and required extensive assist for most activities of daily living (ADLs). R68's care plan dated 2/7/23, indicated R68 had a suprapubic catheter due to urinary retention and was at risk of urinary tract infections. The care plan lacked interventions to keep the catheter off of the floor. R68's care plan dated 3/3/23, indicated R68 had a history of urinary tract infections. R68's urology progress note dated 2/15/23, indicated a urine culture was positive for klebsiella oxytoca (a bacteria that can cause different types of healthcare associated infections), and providencia rettgeri (a bacteria that can cause catheter associated urinary tract…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SHOLOM COMMUNITY ALLIANCE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 07/13/1995 |
| FURMAN, LISA | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| JACOBS, DAVID | Individual | CORPORATE DIRECTOR | — | since 10/01/2024 |
| LAMPERT, RENEE | Individual | CORPORATE DIRECTOR | — | since 10/01/2021 |
| MEICHES, ROBERT | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| MOSOW, DANIEL | Individual | CORPORATE DIRECTOR | — | since 10/01/2024 |
| NIRENSTEIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 07/01/2016 |
| PACKER, FLORENCE | Individual | CORPORATE DIRECTOR | — | since 10/01/2024 |
| PIEROTTI, JEREMY | Individual | CORPORATE DIRECTOR | — | since 10/01/2021 |
| RESIG, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| ROSEN, LAYNE | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| RUTZICK, SHERYL | Individual | CORPORATE DIRECTOR | — | since 07/01/2016 |
| SALITA, MARC | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| SCHANFIELD, PAUL | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| SEGAL, JUDITH | Individual | CORPORATE DIRECTOR | — | since 10/01/2024 |
| SEILER, SCOTT | Individual | CORPORATE DIRECTOR | — | since 07/14/2014 |
| STONE, JONATHAN | Individual | CORPORATE DIRECTOR | — | since 10/01/2021 |
| UNGERMAN, SONIA | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| WEISSMAN, DOUGLAS | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| WOLSON, KIMBERLY | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| BERRYMAN, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/07/2016 |
| MORTENSON, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/13/2025 |
| PEDERSON, JANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| SCHMELING, CORY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/16/2019 |
| WYCKOFF, DOUGLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/13/2025 |
CMS files one row per role, so the 29 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $712K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245411. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.