Cura Of Sandstone
109 Court Avenue South, Sandstone, MN 55072 · Non profit - Corporation · 50 certified beds · (320) 245-3150 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0570)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,345 in federal fines (most recent 2025-12-04)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 4 to 1 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 | 18.2% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.0% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 12.8% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.9% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 4.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 30.7% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.2% | 12.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.3% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.1% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.9% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 75.0% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.7% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 18.2% | 14.8% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.5% 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 37 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 55.6%CMS range 41.9–70.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.2–16.1 | 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 | 40.5% | 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 | 21.6% | 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 | 21.6% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 2.2% | 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 | 6.6%CMS range 3.4–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.65 | 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 50 beds and averages 36.2 residents a day — about 72% occupied, or roughly 14 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 5.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.32 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.06 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 4.52 hrs/resident/day on weekends vs 5.45 on weekdays — 17% thinner on weekends. RN hours go from 1.57 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 · Jcited before2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure safe transfer with a EZ Way smart lift, according to manufacturer's recommendations for 1 of 3 (R1) residents. This resulted in immediate jeopardy (IJ) when R1 fell out of the sling and sustained a contusion to the scalp, closed wedge compression fracture (front part of the vertebrae collapses) of T4 vertebra, and was sent to the Emergency Department (ED). The IJ began on 11/29/25 at 6:00 p.m., when staff, under the age of eighteen, used a full body mechanical lift to transfer R1 from her wheelchair to her bed, did not follow facility policy or manufacturer's instructions, and R1 fell out of the sling. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 11:45 a.m. on 12/4/25. The facility implemented immediate corrective action on 11/30/25, prior to the survey, to prevent recurrence. Therefore, the IJ was issued at past noncompliance.Findings included:R1's care plan dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-08 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate infection control while providing laundry services, as well as failing to maintain an effective Infection Prevention and Control Program specific to infection surveillance. The facility's system did not track culture results, organisms identified, or transmission-based precautions (TBP) initiated to ensure residents received appropriate treatment and infection control measures were maintained. This had the ability to affect all 36 residents. In addition, the facility failed to ensure proper glove use and hand hygiene during care for 1 of 1 resident (R8) during completion of ADL cares.Findings include: Laundry Tour: During a laundry room tour on 4/8/26 at 7:16 a.m., other staff (O)-B was observed sorting dirty laundry without wearing gloves and a gown. O-B lifted dirty laundry from a bin, holding the laundry against themselves, and putting the laundry in a washing machine. During a laundry room tour on 4/8/26 at 7:25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 follow care planned interventions necessary to prevent an avoidable accident from occurring for 2 of 5 (R30, R14) residents reviewed for falls and accidents. In addition, the facility failed to ensure the safety of a resident with suicidal ideations and not following provider orders for safety precautions for 1 of 5 residents (R2) reviewed for accident hazards. Finally, the facility failed to evaluate a resident with an increased risk of aspiration for 1 of 1 residents (R8) reviewed for accident hazards.Findings include: R30: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had moderate cognition, and diagnoses included cerebral infarct (stroke). R30 required assist of 1 staff, gait belt (a belt used as a safety device to support patients when walking) and a 4-wheeled walker for ambulation to/from the bathroom. R30 did not ambulate outside of the bedroom or bathroom. R30's undated Care Plan, identified R30 had…
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 · D2026-04-08 · 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 family/guardian when a resident had a change of condition. This affected 1 of 1 (R8) resident reviewed for change of condition.Findings Include: R8's annual Minimum Data Set (MDS) dated [DATE] indicated R8 had moderate cognitive impairment. Diagnoses included dementia and epilepsy. The MDS indicated R8 was on a mechanically altered diet.R8's care plan undated, identified a potential for altered nutritional status due to hospice. Interventions included a mechanically altered textured diet and to observe, document, and report and signs or symptoms of dysphagia like pocketing, choking, coughing and holding food in mouth.R8's provider orders dated 3/19/25, identified a mechanical soft textured solid food diet with thin liquids.Review of R8's progress notes from 3/19/25 to 3/27/26 were reviewed and indicated the following:From 3/19/25 to 1/11/16, there was no documentation of concerns related to aspiration.on 1/12/26 at 12:14 p.m., R8 was eating…
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 before2026-04-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents with constipation received assessment, effective intervention and notification of the provider for 2 of 5 residents (R2, R3) reviewed for unnecessary medications. This deficient practice had the potential for resident discomfort and medical complications related to constipation. Findings include:R2:R2's quarterly minimum data set (MDS) dated [DATE], identified intact cognition, a diagnosis of slow-transit constipation and occasional bowel incontinence. R2 was dependent for transfers to the toilet and for toilet hygiene.R2's provider orders included 3/3/26, sennosides-docusate sodium (a stool softener) 8.6/50 milligrams (mg) one tab daily for constipation. Orders activated from facility Standing Orders included prunes, prune juice or bananas apples and pears (BAP) as-needed (PRN) for bowel protocol for three days, milk of magnesia (MOM) 30 milliliters (mL) by mouth one time only for constipation, and Dulcolax suppository (a stimulant…
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 · D2026-04-08 · 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 interview and document review, the facility failed to perform a passive range of motion (PROM) program for 1 of 2 (R13) residents reviewed for restorative care.Findings include: R13's annual Minimum Data Set (MDS) dated [DATE] indicated R13 was cognitively intact. Diagnoses included multiple sclerosis (MS) and paraplegia. Section GG indicated R13 had impairment to one upper extremity and both lower extremities. R13's Care Plan undated, indicated a potential for injury related to impaired mobility from paraplegia and MS. Interventions included complete PROM/stretching program once a shift (1 time in morning and 1 time in evening). Copies of PROM program were available at the nurse station 3. R13's PROM documentation from 3/10/26 to 4/8/26 were reviewed and indicated the following:10 shifts were documented as no not performed.14 shifts were documented as not applicable.6 shifts had nothing documented.During an observation on 4/6/26 at 4:23 p.m., R13 was observed to have contractures to her right upper…
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 · D2026-04-08 · 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 attempt to elevate the head of bed (HOB) to prevent aspiration for a resident laying flat with tube feeding (TF) running. This effected 1 of 1 (R28) residents reviewed for TFFindings Include: R28's annual Minimum Data Set (MDS) dated [DATE] indicated R28 had moderate cognitive impairment. Diagnoses included abdominal distention and hemiplegia (complete to total muscle loss to one side of the body). R28 received TF with 51% or greater intake received through TF. R28's care plan undated, indicated a nutritional problem related to a diagnosis of hemiplegia. Interventions included to provide TF and water flushes as ordered. R28's care plan also indicated a risk for aspiration related to TF and inconsistent maintenance of HOB greater than 30 degrees secondary to resident preference/refusal. Interventions included ensure resident is positioned with head elevated greater than 30 degrees with feedings, if refusal for HOB elevation is found then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-08 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 1Number of residents cited: 1Based on interview and document review, the facility failed to ensure the facility antibiotic stewardship program was followed for antibiotic use for 1 of 1 resident (R13) reviewed for antibiotic use.Findings include:R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact. R13's diagnoses included multiple sclerosis, dysuria, obesity, diabetes mellitus type 2, paraplegia, and dementia. R13's care plan dated 3/18/26, identified R13 had urinary incontinence and an indwelling catheter.A nursing note dated 2/23/26 at 3:01 p.m., indicated a message was sent on portal to the provider with an update on R13's urinary color, vaginal discharge, and increasing confusion and agitation.R13's provider orders dated 2/23/26 at 7:00 p.m., included Macrobid 100 mg capsule Give 100 mg by mouth two times a day for Dysuria for 7 Days: Macrobid 100 mg by mouth two times a day for 7 days. The medication was discontinued on 3/2/26.R13's progress…
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 before2026-03-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, interview and document review the facility failed to develop care plans to include enhanced barrier precautions (EBPs) for 2 of 3 residents when nursing assistant (NA)-A was observed lacking required personal protective equipment (PPE) while performing high contact care for R2 who required EBPs.Findings include: During observations on 3/4/26 at 1:05 p.m., an Enhanced Barrier Precautions sign was observed on the door for R2's room, with a personal protective equipment (PPE) cart outside the door. NA-A was observed at the side of R2's bed, wearing only gloves and a mask as PPE. Registered Nurse (RN)-A, an agency nurse, entered the room with a mask, gloves, and a gown. RN-A failed to inform NA-A a gown was also required as a part of the necessary PPE during high-contact cares for R2. NA-A proceeded to assist RN-A with positioning R2. NA-A reached over R2 to turn her to her right side, as R2 did not participate in her own bed mobility. NA-A held R2 on her side while RN-A performed wound care to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · 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 follow established infection control practices for 3 of 3 residents (R1, R2, R3) on enhanced barrier precautions (EBPs) while performing high-contact care.Findings include: During an observation on 3/4/26 at 7:05 a.m., licensed practical nurse (LPN)-A and the director of nursing (DON) performed wound care for R1.- The DON removed two dressings on R1's left foot, discarded them and removed her gloves. The DON failed to perform hand hygiene prior to applying new gloves. She used wound cleanser and gauze to clean the stage II (partial thickness skin loss) left heel wound. She applied calcium alginate (a highly absorbent dressing that creates a moist healing environment) and covered with a bordered foam dressing. Following the application of the dressings to the left heel, the DON changed her gloves but failed to perform hand hygiene.- The DON cleansed the stage III (full thickness skin injury that involves full-thickness skin loss,…
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 · F2025-02-13 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
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 right to weekend mail delivery occurred for 5 of 5 residents (R2, R3, R19, R28, R36) who were reviewed for weekend mail delivery. This deficient practice had the potential to impact all 41 residents who resided at the facility. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact. R3's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R19's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R28's quarterly MDS assessment dated [DATE], indicated R28 was moderately cognitively impaired. R36's quarterly MDS assessment dated [DATE], indicated R2 was cognitively intact. During a group interview on 2/11/25 at 10:11 a.m., the following was said: --- R2 confirmed mail was delivered to the facility on the weekend and indicated packages from delivery places like UPS were also delivered to the facility 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.
Show the remaining 15 citations
- Potential for harm · Fcited before2025-02-13 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 alcohol based hand sanitizer was in use in the hand hygiene dispensers throughout the facility. In addition, the facility failed to ensure oxygen tubing was changed timely for 1 of 1 resident (R11) reviewed for oxygen therapy. Findings include: On 2/10/25 at approximately 2:15 p.m., during resident screenings the hand sanitizer dispensed from the hallway wall dispenser and the dispensers in resident rooms felt watery and was odorless. On 2/11/25 at 2:03 p.m., housekeeper (H)-A stated housekeeping was in charge of refilling the hand hygiene dispensers. When the hand sanitizer fluid was no longer visible in the side window of the dispenser, they would open the dispenser, remove the container and take it to a locked room where the container would be refilled. H-A opened the dispenser and showed the refillable bottle in the dispenser, the bottle was undated. On 2/12/25 at 9:26 a.m., H-B stated Ecolab had stopped making the product they…
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 · E2025-02-13 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to maintain a surety bond (a written agreement to guarantee payment of another company's obligation under a separate contract) to protect the account balance of the resident trust fund. This had the potential to affect 23 of 41 residents at the facility who had a trust account managed by the facility. Findings include: During an interview on 2/12/25 at 9:35 a.m., the office manager (who was responsible for the resident trust funds) pulled up the total balance for the resident trust which was 9,254.77 dollars. The office manager was unable to locate a copy of the surety bond and indicated they would need to follow-up with the corporate office. On 2/13/25 at 10:52 a.m. the administrator stated the corporate office was going to send a copy of the surety bond. On 2/14 /25 at 1:58 p.m., the administrator e-mailed a copy of a document entitled Erisa Dishonesty Bond Edition of 10/1/17, Spring Valley Mutual Insurance Company. The bond indicated it covered employees insured by the employee benefit plans. The document did not include…
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 · E2025-02-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure that temperature-controlled medications were properly stored for 6 of 6 residents (R10, R14, R17, R1, R19, R6) and any resident needing medications from the pharmacy-provided emergency kit, stock vaccine, and tuberculin testing medication. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had diagnoses which included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), diabetes mellitus, and hyperlipidemia. R14's quarterly MDS dated [DATE], identified R14 had diagnoses which included, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), hypertension, diabetes mellitus, hyperlipidemia, arthritis, and dementia. R17's admission MDS dated [DATE], identified R17 had diagnoses which included hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect 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 before2025-02-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure provider orders for medication parameters were followed for 1 of 5 residents (R18) reviewed for unnecessary medications. In addition, the facility failed to ensure provider orders for a fluid restriction and daily weights were followed for 1 of 2 (R142) residents reviewed for hydration. Findings include: R18's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of hypertension (high blood pressure) and repeated falls. R18's care plan dated 2/3/25, identified potential for drug interactions and adverse effects related to the use of multiple medications, and listed interventions to administer medications as ordered and observe for effectiveness and adverse side effects. R18's provider orders contained an order for furosemide (a medication used to help rid the body of water) 20 mg to be given one time per day for hypertension and to hold the medication if R18's systolic blood pressure…
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 before2025-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure aspiration precautions were followed for 1 of 2 residents (R24) reviewed for accidents. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing foods or fluids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). R24's MDS identified R24 had no rejections of care and was cognitively intact. R24's [NAME] as of 2/11/25, identified Special Instructions : No straws (per speech therapy). R24's order review report identified tube feeding diet, no straws per speech therapy dated 3/26/24. On 2/11/25 at 2:49 p.m., R24 was seated in the recliner and on a bedside table next to the chair was a large plastic cup with a straw in the cup. On 2/11/25 at 2:55 p.m., R24 stated they always had a straw in the water cup. On 2/11/25 at 2:57 p.m., registered nurse (RN)- A reviewed…
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 · D2025-02-13 · 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 document review, the facility failed to ensure oxygen was administered as ordered for 1 of 1 residents (R11) reviewed for oxygen therapy. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included treatment for palliative care, anxiety disorder, chronic obstructive pulmonary disease (COPD[a group of lung disease that block airflow and make it difficult to breathe]), macular degeneration (an eye disorder that causes vision loss), and paroxysmal atrial fibrillation (a type of irregular heartbeat where the heart's upper chambers [atria] beat rapidly and irregularly for a short period of time). R11's MDS identified R11 was moderately cognitively intact and used oxygen. R11's care plan initiated on 11/4/24, identified R11 had an alteration in respiratory status related to a diagnosis of COPD with use of oxygen. Interventions included to administer oxygen as order by medical provider (MD). R11's active orders current as of…
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 · D2025-02-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included treatment for palliative care, anxiety disorder, chronic obstructive pulmonary disease (COPD [a group of lung diseases that block airflow and make it difficult to breathe]), macular degeneration (an eye disorder that causes vision loss), and paroxysmal atrial fibrillation (a type of irregular heartbeat where the heart's upper chambers [atria] beat rapidly and irregularly for a short period of time). R11's MDS identified R11 was moderately cognitively intact and had no behaviors or rejections of care. R11's MDS identified R11 used scheduled and PRN pain medications, used…
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 · D2025-02-13 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 resident call lights were within reach from the bathroom floor in multi-resident bathrooms for 3 of 3 residents (R24, R11, R30) reviewed for call light accessibility. Findings include: On 2/10/25 at 1:58 p.m., R24's shared bathroom call light was checked to see if it worked and if it was accessible from the floor. The call light was a white cord that was looped and attached to a hook approximately four feet from the floor. On 2/10/25 at 5:24 p.m., R11's shared bathroom call light was checked to see if it was in working order and if it was accessible from the floor. The call light cord was approximately 10 inches from the floor. On 2/10/25 at 6:42 p.m., R30's bathroom call light was checked to see if it was in working order and for accessibility from the floor. The call light was approximately 14 inches from the floor. On 2/12/25 at 9:10 a.m., maintenance (M)-A checked R11's bathroom call light and removed it from the hook in the wall and measured. When the call light was freed from the hook in 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 · E2024-01-05 · tag F0609 — failed to report abuse allegations — patternTimely 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 interview and record review the facility failed to report misappropriation of resident's property to the state agency immediately, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 3 of 3 residents (R1, R2, and R3) when narcotic medications were missing and not accounted for out of resident's medications cards. Findings include: R1's physician medication order dated 12/13/23 indicated R1 was to be administered morphine ER 30 milligram (mg) by mouth twice a day. R1 received a signed medication order on 12/13/23 for oxycodone-Acetaminophen 10-325mg tablet my mouth twice a day as needed. Morphine and oxycodone-Acetaminophen are both narcotic medications. During an interview with R1 on 1/5/24 at 9:22 a.m., R1 stated that the administrator had told her that three of her narcotic medications were missing a couple of days ago. R1 stated that the administrator told her that they know who took the medications, but they still have to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 privacy during personal cares for 1 of 5 residents (R143) observed during personal cares. Findings include: R143's quarterly Minimum Data Set, dated [DATE], indicated R143 was cognitively intact and had diagnoses of paraplegia, diabetes, seizure disorder, and depression. During an observation on 11/1/23 at 8:34 a.m., R143's large picture window was covered with vertical slat blinds. There were three vertical slats missing from the window blinds, not allowing for full privacy. The parking spaces along the building outside of R143's window were visible through the missing slats. A car license plate could be read from the door side of R143's room when looking out through the spaces created by the missing blind slats. During an observation on 11/1/23 at 8:48 a.m., the assistant director of nursing (ADON) entered R143's room and positioned R143 so that R143's back side faced the window with the missing vertical blinds. ADON-B lowered…
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 before2023-11-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, interview and document review, the facility failed to develop a comprehensive care plan to identify and direct staff to care for 1 of 1 resident (R11) reviewed for diabetic care. Findings include: R11's admission Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact and received insulin injections during the last seven days of the assessment period. Diagnosis of diabetes mellitus. R11's Order Summary Report as of 11/3/23, directed staff to do the following: - 9/7/23, check blood sugars four times a day before meals and at bedtime related to type 2 diabetes mellitus - 9/7/23, glucagon emergency injection solution 1 milligram (mg) per milliter (ml) 1 mg subcutaneously every 15 minutes as needed for type 2 diabetes mellitus - 9/7/23 glucose oral chew tablets 4 grams (gm) every 15 minutes as needed for type 2 diabetes mellitus - 9/7/23 glucose 15 oral gel 40% give 30 gm by mouth every 15 minutes as needed for type 2 diabetes mellitus 9/21/23, provide a liberal diabetic diet…
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 · D2023-11-03 · 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 observation, interview and document review the facility failed to provide timely assistance with toileting for 1 of 1 resident (R13) reviewed for activities of daily living and were dependent on staff assistance. Findings include: R13's annual Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact, had no rejection of cares, was frequently incontinent of urine, and was dependent on staff for activities of daily living. R13's MDS included diagnoses of diabetes mellitus with complications, morbid obesity, depression, chronic pain syndrome, and functional quadriplegia. R13's undated, care plan included an intervention of staff to offer assistance with the bed pan every two to three hours and as needed. On 11/1/23, R13 was observed continuously from 7:17 a.m. to 9:20 a.m. and identified the following: -at 7:17 a.m., R13's door was open R13 was observed lying in bed on her back, the lights were on she was wearing oxygen per nasal cannula. -at 8:20 a.m., nursing assistant (NA)-A brought R13…
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 · D2023-11-03 · 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 residents were repositioned timely who were at risk for pressure ulcers for 2 of 2 residents (R13, R35) reviewed for pressure ulcers. Findings include: R13: R13's annual Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact, had no rejection of cares, was frequently incontinent of urine, and was dependent on staff for activities of daily living. R13 was at risk for developing pressure ulcers. R13's MDS included diagnoses of diabetes mellitus with complications, morbid obesity, depression, chronic respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and functional quadriplegia. R13's undated care plan, included an interventions of turning and repositioning every two to three hours as tolerated and as needed. R13's undated, nursing assistant (NA) care…
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 · D2023-11-03 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure routine dental services were provided for 1 of 1 resident (R1) reviewed for dental services. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was sometimes understood, had memory and comprehension problems, and had physical and verbal behaviors. R1's MDS identified diagnoses which included dysphagia (difficulty swallowing), intracranial injury sequela, aphasia (disorder caused by damage in a specific area of the brain that controls language and expression) and anxiety. R1's undated care plan identified R1 had an alteration in oral hygiene related to natural teeth and often refused cares. R1 was identified as at risk for infection. Interventions included to observe for signs and symptoms of infection to oral cavity. Referral to dentist as needed per family's request. R1's Health Drive Dental Group dated 7/17/23, identified heavy generalized plaque buildup and severe gingival inflammation. 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 before2023-11-03 · 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 proper hand hygiene was utilized during wound care for 2 of 6 residents (R143, R10) observed during wound care. In addition, the facility failed to ensure proper hand hygiene was completed during cares for 1 of 1 resident (R13) observed for cares. Findings include: R10: R10's Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact and had been admitted to hospice services. During an observation on 11/1/23 at 3:07 p.m., the assistant director of nursing (ADON) sanitized their hands and applied gloves, removed R10's right heel dressing, cleansed wound with normal saline, measured the wound, placed the heel on a 4x4 on the bed, removed gloves, sanitized hands, put new gloves on, and then dated the dressing and applied it to the right heel wound. ADON returned to the room with more gauze, sanitized hands, applied gloves, and set a new dated dressing on R10's bed. ADON then removed the old drainage saturated dressing…
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
$17,345 in federal fines across 1 penalty.
- $17,345 — penalty dated 2025-12-04
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CURA — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.5 | -1.5 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 1 of 5 | 2.0 | -1.0 vs chain |
The other 7 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OPATZ, TOM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 05/01/2017 |
| STRUZYK, FRED | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 05/01/2017 |
| TF MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2017 |
| COLBY, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/1996 |
| ERVIN, DEREK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/28/2022 |
| JOHNSON, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/06/2024 |
| LINDBERG, KALLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/03/2024 |
| LUDWIG, CYNTHIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/24/2023 |
| MEYER, LUNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/10/2024 |
| STRATE, LAWRENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2017 |
| SANDSTONE HEALTH CARE CENTER LLC | Organization | ADP OF THE SNF | — | since 05/01/2017 |
CMS files one row per role, so the 19 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 245454. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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.