Good Shepherd Lutheran Home
1115 4th Avenue North, Sauk Rapids, MN 56379 · Non profit - Church related · 146 certified beds · (320) 252-6525 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit 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 | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 held steady at 5 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 | 16.2% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.0% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.2% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.2% | 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 | 2.7% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.3% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.7% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 90.6% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.8% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.0% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.94 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.68 | 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.
57.6% 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 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.5% 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 169 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 57.6%CMS range 47.4–66.4 | 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 | 9.7%CMS range 6.3–12.9 | 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 | 61.5% | 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 | 56.8% | 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 | 48.5% | 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 | 98.0% | 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 | 96.3% | 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 | 98.4% | 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 | 1.0% | 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 | 6.1%CMS range 3.0–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 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 146 beds and averages 125.1 residents a day — about 86% occupied, or roughly 21 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.27 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 4.36 hrs/resident/day on weekends vs 5.15 on weekdays — 15% thinner on weekends. RN hours go from 1.01 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2026-07-09 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all residents currently residing in the facility, as well as all staff and visitors. Findings include: On 7/8/26 at 8:47 a.m., it was observed that RBOR poster was displayed in a locked glass case in a small common area near the entrance and was dated 1/16. On 7/8/26 at 12:02 p.m., director of Social Services confirmed the poster was outdated and a new one needed to be ordered. A facility policy was requested but none provided.
- Potential for harm · Dcited before2026-07-09 · 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 record review the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 2 of 2 residents (R2, R69) reviewed for medication administration.Findings include:R69's comprehensive MDS assessment dated [DATE] indicated R69 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and renal insufficiency.R69's self-administration of medication inquiry form signed by R69 on 4/15/26 indicated R69 did not want to self-administer medications either independently or after set-up by facility staff.During observation and interview on 7/6/26 at 11:04 a.m., a bottle of Nystatin powder with a pharmacy label containing R69's name was observed on the dresser.R69's orders reviewed on 7/8/26 lacked an order for self-administration of medication.R2's quarterly minimum data set (MDS) assessment dated [DATE], indicated R2 was cognitively intact and had 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 · D2026-07-09 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to promote independence for 1 of 1 resident (R 72) reviewed for self determination.Findings include: R72's face sheet printed 7/9/26, indicated admission date of 4/10/25, and had diagnoses of Cerebral Infarction affecting left side, type 2 Diabetes, and difficulty in walking. R72's care plan printed 7/9/26, indicated at risk for falls, resident needs a safe environment with even floors free from clutter, when in bed place blue mats on each side of the bed.During observation and interview on 7/7/26 at 5:02 p.m. R72 was sitting in wheelchair with a blue mattress on the floor opposite side of the bed and blocking access to the refrigerator. R72 stated he was not able to access his pop or yogurt that was in the refrigerator. During observation on 7/8/26 at 4:48 p.m. R72 was sitting in his wheelchair. There were 2 blue mats on the floor opposite side of bed and blocking access to the refrigerator. on 7/9/26 at 8:09 a.m. nursing assistant (NA)-A stated resident needed assistance with activities of daily living (ADLs) and keeping his…
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 · D2026-07-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 2 of 6 resident reviewed for bedrails. Findings include: R55's comprehensive minimum data set (MDS) dated [DATE] indicated R55 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and arthritis. Section P of the MDS which covers restraints and alarms indicated R55 did not use bedrails. During observation and interview on 7/6/26 at 10:24 a.m., R55's bed was noted to have quarter bed rails attached to the top portion of the right and left side of the bed. R55 stated they had been there since her admission. R55's medical record was reviewed and did not indicate the use of bedrails. R16's quarterly MDS assessment dated [DATE] indicated R16 was cognitively intact and had the following diagnoses: coronary artery disease, heart failure, and high blood pressure. Section P of the MDS which covers restraints and alarms indicated R16 did not use bedrails. During…
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 · D2026-07-09 · 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 record review, and interview, the facility failed to update the provider of a weight change per physician order for 1 of 5 residents (R8) reviewed for unnecessary medications.Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 was mildly cognitively impaired, was admitted on [DATE], and had the following diagnoses: coronary artery disease, heart failure (HF) (hearts failure to pump blood efficiently and can cause weight fluctuation), hypertension (HTN) (high blood pressure), and dementia.R8's clinical physician orders dated 7-9-26, indicated the following order:daily weight- every day shift (REPORT CHANGE OF 3LBS OVERNIGHT). Start date 4-9-26R8's weights and vitals dated 7-9-26, indicated the following weight fluctuations:On 5-29-26 weight-153.5lbsOn 5-30-26 weight-149.5lbs, which showed a change of 4lbs.On 6-3-26 weight-148.5lbsOn 6-4-26 weight-153.5, which showed a change of 5lbs.R8's medical record lacked any evidence that the provider was ever updated per the provider…
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 · D2026-07-09 · 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 resident receive adequate supervision and assistance for 1 of 1 resident (R5) when transferred with and EZ stand lift.Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated cognitive deficit and dependent for toileting, Diagnoses included: Alzheimer's disease, dementia, fracture, and repeated falls. R5's care plan printed 7/8/26, indicated moderate risk for falls related to weakness. Toileting: EZ stand w/2A [with 2 assist]. Does not ambulate at this time. During observation on 7/6/26 at 1:49 p.m., nursing assistant (NA)-D entered R5's room with EZ stand. NA-D placed harness, safety belt and loops appropriately. NA-D asked R5 if she was awake and proceeded to raise the arms. R5 stood at approximately 135 degrees, never coming to a full stand. NA-D grabbed the back of R5's pants during transfer to toilet. R5 was allowed some privacy, but remaining by door of bathroom. Staff re-entered bathroom to assist…
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 · D2026-07-09 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives prior to use of bed rails for 2 of 6 residents (R55, R16 ) reviewed for bed rails. Findings include:R55's comprehensive minimum data set (MDS) dated [DATE] indicated R55 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and arthritis. Section P of the MDS which covers restraints and alarms indicated R55 did not use bedrails. During observation and interview on 7/6/26 at 10:24 a.m., R55's bed was noted to have half-length bed rails attached to the top portion of the right and left side of the bed. R55 stated they had been there since her admission, and she did not routinely use them. R55's medical record was reviewed and lacked an assessment, or consent and education for the use of bedrails. R16's quarterly MDS assessment dated [DATE] indicated R16 was cognitively intact and had the following diagnoses: coronary artery disease, heart failure,…
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 · D2026-07-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to transcribe orders according to standards of practice for medication management for 1 of 5 (R150) residents reviewed for unnecessary medications.Findings include:R150's undated faceheet indicated they were admitted on [DATE], and had the following diagnoses: restlessness and agitation, pain, palliative care, and a frontotemporal neurocognitive disorder. R150's clinical physician orders dated 7-9-26, indicated the following order: Ativan 0.5mg solutabs- Give 0.25mg by mouth every 4 hrs as needed for restlessnessR150's corresponding narcotic book page associated with the Ativan order, showed the following: Ativan 5mg three times a day (TID) q4hr PRNR150's bubble pack card for Ativan listed the following: Lorazepam (Ativan) 0.25mg solutab-dissolve 1 tablet (0.25mg) by mouth three times a day AND dissolve 1 tablet by mouth every 4 hours as needed. The pharmacy card did not include a sticker or any other connotation which would have indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and interview, the facility failed to ensure medications were labeled with an opened-on date as well as an expiration date for 1 of 4 medication carts (500 wing cart) reviewed for medication storage and labeling.Findings include:On [DATE] at 1:50 p.m., during review of the 500 wing medication cart with licensed practical nurse (LPN-A) the following was observed: 1 Lantus insulin pen with no expiration date noted.A box containing 2 bottles of Systane eye drops: bottle 1 indicated an open date of [DATE], but lacked an expiration date. Bottle 2 lacked both an opened on and expiration date. LPN-A stated when new medications were delivered the nurse who received the medications was to place an opened-on/Expired sticker on the medication and when the medication was first used that date, as well as the expiration date was written on the sticker. LPN-A opened medication cart to demonstrate the process, however, could not find any of the stickers needed for proper labeling. LPN-A stated without 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 · F2025-04-17 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 114 residents residing in the facility and their visitors who may wish to view the information. Findings include: On 4/14/25 at 1:21 p.m., the posted nurse staffing information dated 4/14/25, was observed in a clear, plastic cover on the visitor sign-in table. However, the nurse staffing information lacked the total number and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the nurse staffing information lacked the resident census. On 4/15/25 at 2:12 p.m., the posted nurse staffing information dated 4/15/25, lacked the total number, and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the posting lacked resident census. On 4/16/25 at 7:18 a.m., the posted nurse staffing information dated 4/16/25, lacked the total…
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 14 citations
- Potential for harm · F2025-04-17 · 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
Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding drug storage. This had the potential to affect all 114 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 3/17/25, indicated the facility was cited F761 for drug storage on the survey exited 5/2/24. See F761: Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts. The facility's QAPI meeting minutes dated 3/13/25, lacked ongoing data related to the above repeat citation. On 4/17/25 at 10:45 a.m., the quality assurance registered nurse (RN)-B acknowledged the importance of continued monitoring of prior Performance Improvement Projects (PIPS). RN-B stated formal auditing and then more periodic auditing, chart review, and observational audits, were completed to ensure improvements…
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 · E2025-04-17 · 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 food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to maintain the ice machines in a sanitary manner to prevent potential food-borne illness. This deficient practice had the potential to affect all 116 residents who received food, beverages, and ice from the refrigerators, kitchen and ice machine. Findings include: On 4/14/25 at 10:44 a.m., during the kitchen tour with the dietary supervisor (DS), the following concerns were identified: Produce cooler: -1/4 container of yogurt without notation of an open date. -3/4 container tartar sauce without notation of an open date. -1/4 container mayonnaise without notation of an open date or an expiration date, and a foul odor when container was opened. Stand up freezer: -1/4 bag of sausage without notation of an open date or expiration date. -3/4 bag of pepperoni without notation of an open date or expiration date. -1/2 container of pork Salisbury steak without notation 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 · Dcited before2025-04-17 · 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 nebulizer medications were administered safely for 1 of 3 resident s (R5) who were observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnosis which included arthritis, hypertension (elevated blood pressure ) and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). Further, R5 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R5's care plan dated 3/4/24, identified R5 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance. R5's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Directed staff to administer medications as ordered. Review of R5's electronic health record (EHR)…
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 F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 standards of practice related to medication administration of an inhalation medication for 1 of 3 residents (R5) observed for medication administration. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnosis which included arthritis, hypertension (elevated blood pressure ) and and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). Indicated R5 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R5's care plan dated 3/4/24, identified R5 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance. R5's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Directed staff to administer medications as ordered. R5's Order Summary Report dated 2/18/25, directed staff to administer Budesonide…
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 timely assistance with repositioning occurred for 1 of 4 residents (R12) with a current pressure ulcer and at risk for further development of pressure ulcers. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition and diagnosis which included arthritis, anxiety disorder and paraplegia (paralysis of the legs and lower body). Identified R12 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting R12's annual Care Area Assessment (CAA) dated 8/2/24, identified R12 was a at risk for skin breakdown and had a pressure ulcer to her left gluteal fold. Identified R12 required extensive assistance to reposition in bed and wheelchair. she required a regular turning schedule. R12's care plan revised 10/4/24, identified R12 had a chronic wound to her right gluteal fold. Care plan directed staff to reposition R12 every two…
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 F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts. Findings include: On 4/15/25 at 9:12 a.m., medication cart on locked memory care unit was observed to be unlocked. Medication cart was in a common area. Medication cart remained unlocked while staff walked past unlocked medication cart. On 4/15/25 at 2:44 p.m., medication cart on 100 wing of the facility was observed being unlocked. At 2:46 p.m., staff walked past medication cart to pass water. Cart remained unlocked. At 2:48 p.m., staff walked past cart with housekeeping cart. Cart remained unlocked. At 2:49 p.m., registered nurse (RN)-B was observed coming out of spa room and walking down hall away from medication cart. Medication cart remained unlocked. At 2:50 p.m., RN-B re-entered locked spa room. Cart remained unlocked. AT 2:53 p.m., RN-B walked from spa to nurse's office out of direct eyesite of medication cart. Cart remained unlocked. At 2:54 p.m., staff passed medication cart while pushing a…
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 F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 served at a palatable and appetizing temperature for 3 of 3 residents (R 5, R16, and R13) who resided on the North shore unit, reviewed for food. This deficient practice had the potential to affect all 21 residents residing on this unit. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 had intact cognition ad was able to feed herself after staff set up her tray. R16's significant change MDS dated [DATE], indicated R16 had intact cognition and could feed herself after staff set up her tray. R13's admission MDS dated [DATE], indicated R13 had intact cognition and could feed himself after staff set up his tray. During an interview on 4/14/25 at 2:00 p.m. R5 stated the food was not always hot by the time they were served on this unit. During an interview on 4/14/25 at 3:56 p.m., R16 stated the food was not always served very hot especially the meat and potatoes. During an interview on 4/14/25 at…
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 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 personal protective equipment (PPE) was used when providing cares for 1 of 1 residents (R80) reviewed for enhanced barrier precautions (EBP). Findings include: R80's admission Minimum Data Set, dated [DATE], included R80 had moderate cognitive impairment. R80 had diagnosis of COVID-19, depression, and metabolic encephalopathy (a condition causing altered metal status). R80's undated care plan, included R80 was on EBP due to a pressure ulcer on buttocks. Care plan included to wear a gown and gloves when providing high contact cares. On 4/15/25 at 9:21 a.m., licensed practical nurse (LPN)-B was observed in R80's room cutting her toenails. LPN-B was not wearing a gown and was leaning on foot of bed. During interview on 4/15/25 at 9:25 a.m., LPN-B confirmed R80 was on EBP for a pressure ulcer. LPN-B confirmed she had received education on EBP and should be wearing PPE whenever providing close contact cares. LPN-B confirmed she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-02 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 records of a thorough investigation for 4 of 4 residents (R29, R318, R319, R50) related to facility reported events. Findings include: On 8/30/23 at 11:42 a.m., the facility submitted an incident report to Minnesota Department of Health (MDH) regarding possible allegations of financial exploitation for R29. R29 had reported her tablet had been missing, and after searching felt someone had taken it. Report indicated that Sauk Rapids police department (PD) had been notified, and no alleged perpetrator (AP) had been identified. On 9/6/23 at 4:32 a.m., the facility submitted a five day incident report to MDH with an overall summary of the event and their investigation summary. The investigation summary noted R29 history of losing tablet in the past, but not being able to find this time, resulting in a report filing. Tablet remains missing with no identified AP's at this time. Facility will continue to investigate. Report indicated R29 most recent BIMS of 15, interviewing of staff, and resident conducted. On 5/2/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-02 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 2 of 2 residents (R48, R108) reviewed for dialysis. Findings include: During observation on 04/29/24 at 2:20 p.m., R48 was in bed with long sleeve sweater covering both arms. R48 was able to adjust sweater sleeve with assistance from family member to show clean, dry and intact dressing she received at dialysis center earlier that day. R48 stated the staff would remove the dressing but was unsure a what time they typically removed the dressing. R48's admission record dated 5/2/24, included diagnosis of end stage renal disease (ESDR), chronic kidney disease [NAME] 4 (severe), fluid overload, type 2 diabetes, and dependence on renal dialysis. R48's order summary report dated 5/2/24, included an order for a 1500 milliliter (mL) fluid restriction, dialyvite oral tablet one time a day for ESDR, and lidocaine-prilocaine external cream 2.5-2.5% to affected area topically one time a…
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 · D2024-05-02 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 5 residents (R42, R49), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital. Findings include: R42's significant change minimum data set (MDS) dated [DATE], indicated intact cognition. Diagnoses included heart and renal failure. R42's progress notes indicated hospitalization from 2/14/24 through 2/19/24. R42's Ombudsman Notification of Discharge form, dated 2/14/24, indicated R42 would be transferred to the hospital on 2/14/24 due to R42's emergent medical need. The bottom section of the form indicated a copy of this notice has been sent to the office of ombudsman for LTC with a fax number. However, the areas for date and staff signature were left blank. R49's significant change MDS dated [DATE], indicated severe cognitive impairment. Diagnoses included heart failure and quadriplegia. R49's progress notes…
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 · D2024-05-02 · 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 interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed resident dialysis care for 2 of 2 residents (R48, R108) reviewed for dialysis. Findings include: R48's admission record dated 5/2/24, included diagnosis of end stage renal disease (ESDR), chronic kidney disease [NAME] 4 (severe), fluid overload, type 2 diabetes, and dependance on renal dialysis. R48's undated care plan printed 4/30/24, included enhanced barrier precautions due to Hemodialysis catheter. R48's care plan included the need for dialysis related to renal failure. Approaches included to not take blood pressure or blood draws from arm with graft (a type of access for dialysis). Care plan included to encourage resident to go to scheduled dialysis appointments on Monday, Wednesday and Friday. Care plan included to monitor/document/report signs of infection at the access site PRN (as needed), signs and symptoms of renal insufficiency PRN, and to monitor for signs and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · 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
Based on observation, interview and document review, the facility failed to provided bathing for 1 of 2 residents (R34) reviewed for dependent cares. Findings include: Quarterly minimum data set (MDS) submitted 3/5/24 reported R34 required partial to moderate assistance for shower/bathing. This response indicated R34 required assistance from a helper to complete the task. R34's admission record printed 5/2/24, included diagnoses of chronic pain syndrome, major depressive disorder (depression), and generalized anxiety disorder (anxiety). R34's bathing task report for 30 days included one response of resident refused on 4/3/24. No other responses documented. R34's progress notes failed to include notes regarding offering of bathing assistance or refusal of bathing assistance. During interview on 4/29/24 at 12:26 p.m., R34 stated she it had been a month since she had received a bath. R34 stated she often would not feel well when staff would come to give her a bath and would request a bath at a later time. R34 stated staff would not be available to give her a bath at the time she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 6 facility medication carts. Findings include: On 4/29/24 at 4:43 p.m., medication cart on 100s wing of facility was observed unlocked. Facility staff was observed walking past medication cart to the dining room to fill a pitcher of water. She then walked past the unlocked medication cart again and continued down the hallway to a resident's room. Facility staff returned to the medication cart at 4:55 p.m. and locked the cart. During the observed time, the medication cart was out of direct eye site of the staff member. On 4/30/24 at 3:35 p.m., medication cart on 300s wing of facility was observed to be unlocked and unattended until 3:40 p.m. On 5/1/24 at 7:22 a.m., medication cart on 100s wing of facility was observed to be unlocked and unattended. Medication cart was observed being unlocked for approximately one minute before facility staff approached the medication cart to lock it. At 11:51 a.m. on 5/2/24, registered nurse…
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 | Since |
|---|---|---|---|
| BACON, DENNIS | Individual | CORPORATE DIRECTOR | since 04/27/2023 |
| CLOETER, PAUL | Individual | CORPORATE DIRECTOR | since 07/30/2020 |
| KIRCHOFF, BARRY | Individual | CORPORATE DIRECTOR | since 06/17/2021 |
| LEONARD, CHARLES | Individual | CORPORATE DIRECTOR | since 04/29/2025 |
| LOIDOLT, GARRY | Individual | CORPORATE DIRECTOR | since 04/29/2025 |
| MACHULA, JENNIFER | Individual | CORPORATE DIRECTOR | since 07/30/2020 |
| PERLEBERG, LOIS | Individual | CORPORATE DIRECTOR | since 06/16/2022 |
| SCAPANSKI, CHERYL | Individual | CORPORATE DIRECTOR | since 11/10/2022 |
| STROHSCHEIN, DAVID | Individual | CORPORATE DIRECTOR | since 06/27/2019 |
| ZOELLER, DAVID | Individual | CORPORATE DIRECTOR | since 04/17/2018 |
| FITCH, MIKE | Individual | CORPORATE OFFICER | since 04/17/2018 |
| STORDAHL, MICHAEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/28/2018 |
| BARBER, JACQUELYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/27/2008 |
| MARTINI, KRISTA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/20/2002 |
| SCHOEPHOERSTER, GEORGE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/07/2017 |
| AEGIS THERAPIES, INC. | Organization | ADP OF THE SNF | since 01/01/2018 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | since 11/14/2022 |
| KLEVER, EMILY | Individual | ADP OF THE SNF | since 08/08/2014 |
CMS files one row per role, so the 23 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 245269. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-09, 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 →
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