Shakopee Friendship Manor
1340 Third Avenue West, Shakopee, MN 55379 · For profit - Corporation · 60 certified beds · (952) 445-4155 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)
- a high payroll-based staffing rating (4/5)
- 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 (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,378 in federal fines (most recent 2026-05-08)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.6% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.7% | 4.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.5% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.1% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.3% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.8% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.6% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 17.1% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 5.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 64.9% | 82.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.5% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.8% | 14.8% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 45.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.0% | 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 | 45.0% | 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 | 35.0% | 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 | 81.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.8% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 50.9 residents a day — about 85% occupied, or roughly 9 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 5.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.41 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 4.69 hrs/resident/day on weekends vs 5.23 on weekdays — 10% thinner on weekends. RN hours go from 1.12 to 0.51 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · J2026-05-08 · 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 a mechanical lift was used in accordance with manufacturer's guidelines and Federal law to complete a safe transfer for 1 of 3 residents (R1) reviewed who used mechanical lifts. Two nursing assistant (NA) staff members, one of which was not [AGE] years of age, attempted to transfer R1 using the lift, but did not properly secure the sling to the device prior to lifting R1 up. This resulted in R1 falling onto the floor and sustaining multiple injuries including a fractured shoulder and head laceration. These findings constituted an immediate jeopardy (IJ) situation for R1. The IJ began on 5/3/26 when the two NA staff members failed to fully connect the lift sling to the device, nor did they double check the sling attachment prior to initiating the transfer of R1. R1 was raised from the bed with only three of the four attachment points placed which caused R1 to fall from the sling onto the floor and sustain serious physical…
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 before2025-09-22 · 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 signs of a potential gastrointestinal (GI) bleed were acted upon or evaluated timely and, if needed, referred for care or treatment to reduce the risk of complication for 1 of 1 residents (R1) reviewed who was hospitalized with GI complications. Findings include: R1's Entry Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the care center on 9/15/25 from the acute care hospital. R1's initial Medicare/5-Day MDS remained, In Progress, at the time of survey.R1's Interagency Transfer Form, dated 9/10/25, was completed by the admitting hospital and outlined R1 as having a past medical history significant for colon cancer and chronic kidney disease (CKD). The report outlined R1 admitted to the hospital on [DATE] after a mechanical fall with a resulted odontoid fracture (i.e., a form of cervical fracture). R1's medical history was detailed which included a history of right hemicolectomy (a surgical procedure that involves removing the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-23 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) were completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident (R30) reviewed for PASARR. Findings include:R30's significant change Minimum Data Set (MDS) dated [DATE], indicated R30 had moderate cognitive impairment, did not have delusions, hallucinations or behaviors.R30's Clinical Diagnosis Report printed 7/23/25, indicated R30 was admitted on [DATE] and indicated diagnoses of paranoid schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior, primarily marked by paranoid, delusions and hallucinations), cerebral infarction (area of damaged tissue on the brain), muscle weakness, drug induced dyskinesia (uncontrolled, involuntary muscle movement), diabetes, and hypertension.An attached Fax from Senior LinkAge Line, dated 4/5/23,…
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 before2025-07-23 · 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, intervention, and document review, the facility failed to develop a comprehensive care plan to ensure safety with wandering behaviors for 1 of 1 residents (R9) reviewed who had a history of wandering. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had severe cognitive impairment and was dependent on staff during the lookback period (LBP) to use her manual wheelchair. The MDS indicated R9 had not wandered during the LBP. R9's progress note dated:-3/24/25 at 10:14 p.m., indicated R9 had been wandering trying to find the doctor's office. -4/1/25 at 9:36 p.m., indicated R9 was often wandering down halls and 1:1 and redirection had been effective interventions. -4/2/25 at 3:25 p.m., indicated R9 was wheeling herself into other residents' rooms and attempting to push a wheelchair that was in the hallway. -4/7/25 at 3:01 p.m., indicated R9 was wheeling herself in her wheelchair around the unit and yelling at the laundry lady to come back here. The note…
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 · D2025-07-23 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a change with hearing ability was acted upon, fully evaluated and, if needed, treated or referred to the audiologist for 1 of 1 residents (R1) reviewed who complained about worsening hearing. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking. Further, the MDS recorded R1 as having, Adequate, hearing with no hearing aid use.On 7/21/25 at 1:43 p.m., R1 was observed seated in a recliner chair while in her room. R1 did not have any hearing aids or audio devices present on her at this time. R1 was interviewed and stated her hearing in the left ear had been getting worse which concerned her. R1 was asked if they'd been seen by the audiologist for this and abruptly laughed stating, I can't afford it. R1 was hard-of-hearing during the interview and would often times turn her head to the left side and respond, Say again[?], to 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 before2025-07-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 recorded complaints of pain or discomfort were comprehensively assessed and, if needed, interventions developed to ensure adequate comfort for 1 of 2 residents (R12) reviewed for pain management. Findings include: R12's quarterly Minimum Data Set (MDS), dated [DATE], identified R12 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS recorded R12 as consuming scheduled pain medication, but having no as-needed (i.e., PRN) medications or non-pharmacological interventions done for pain. Further, the MDS recorded R12 as, Frequently, having pain with a moderate intensity recorded. On 7/21/25 at 1:57 p.m., R12 was observed seated in her wheelchair while in her room. R12 demonstrated no obvious physical symptoms of pain at this time (i.e., grimacing, moaning), however, when interviewed she expressed having pain in her legs and knees due to a fall which happened awhile ago. R12 explained she was currently…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · 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 interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R29) reviewed for dignity. Findings include: R29's significant change in status Minimum Data Set (MDS), dated [DATE], indicated R29 was admitted in 2/26/24, had intact cognition and required maximum assistance for toileting, dressing lower part of body, footwear. R7 required moderate assistance from staff for personal hygiene, dressing upper part of body, shower/bathing. MDS further identified, R7 was dependent on staff for sitting to standing and transfers. Noted for toilet transfer, resident refused. R29's MDS indicated no behaviors were present, and no rejection of care exhibited. Section V: Care Area Assessment (CAA) summary, the following care areas were triggered and marked as addressed in care plan: communication; ADL function/rehabilitation potential; urinary incontinence and indwelling catheter; psychosocial…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · 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 implement and maintain enhanced barrier precautions (EBP) for 1 of 1 residents (R22) reviewed for transmission based precautions. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was admitted to the facility on [DATE], had intact cognition and diagnoses of hemiplegia (paralysis) affecting right dominant side and rhabdomyolysis (condition where damaged muscle fibers leak into the blood, causing kidney and heart problems). R22's progress note (PN) dated 5/22/24, indicated R22 was sent to emergency room for urinary retention and returned to facility with a foley catheter in place. R22's physician note dated 5/30/24, documented R22 was transferred to the ER on [DATE], with symptoms of urinary retention and a catheter was placed and, Will be discharged home with a leg bag. R22's care plan (CP), physician orders (PO) and [NAME] (nursing assistant care sheet) downloaded on 6/4/24, lacked mention of a foley…
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 before2023-05-18 · 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 document review, the facility failed to comprehensively assess and monitor bruises for 1 of 1 resident (R22) reviewed for non-pressure related skin conditions. Findings include: R22 was admitted to the facility on [DATE]. Diagnosis listed on the Physician Order sheet dated 5/16/23, located in the medical record included; osteoporosis (bones become week and brittle), Alzheimer's disease (a progressive disease that destroys memory and other mental functions), macular degeneration (eye disease that causes vision loss), and mood and anxiety disturbance (mental health disorder characterized by feelings of worry, and fear that interfere in ones daily activities). During observation and interview on 5/15/23 at 1:59 p.m., R22 was noted to have a large dark bluish bruise on the top of the right hand. The bruise covered the entire top of the hand. R22 indicated she was not sure how she got the bruise, and unsure if they were improving or worsening. R22's quarterly Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · 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 comprehensively assess and implement interventions for 1 of 1 resident (R1) who was at risk for pressure ulcers (PU) and currently had a pressure ulcer. Findings include: R1 was admitted to the facility on [DATE], with diagnoses identified on the active physician order sheet, dated 5/17/23, including; fracture of the vertebrae (dislocation/fracture of the backbone), muscle weakness (decreased strength in the muscles), osteoarthritis (tissue at the ends of the bone wears down) and pain in the thoracic spine. R1's admission minimum data set (MDS) dated [DATE], identified R1 as having a baseline interview for mental status (BIMS) of 12 (moderately impaired cognition). R1 required extensive assistance with activities of daily living (ADL's) that included bed mobility. The MDS identified R1 as being at risk for PU's and identified a unhealed stage 2 pressure ulcer. Review of the admission data collection form dated 4/19/23, identified R1 as…
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 before2023-05-18 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 comprehensively assess and develop interventions to proactively provide comfort and ensure adequate pain-relief measures were in place for 1 of 1 resident (R29) reviewed who was non-verbal and demonstrated potential physical signs of pain (i.e., teeth grinding, grimacing). Findings include: R29's significant change Minimum Data Set (MDS), dated [DATE], identified R29 had severely impaired decision-making but demonstrated no rejection of care behaviors. In addition, the MDS outlined R29 was totally dependent on staff for their activities of daily living (ADLs), consumed scheduled pain medication only, and demonstrated no indicators of pain or possible pain in the last five (5) days. Further, the Care Area Assessment (CAA) for pain did not trigger to be completed. R29's most recent Pain Interview (3.0) - V3, dated 4/21/23, identified instructions to complete the evaluation if the resident was able to communicate properly. If they were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility consulting pharmacist failed to address the continued use of psychoactive medications for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnoses (identified on the physician order sheet in the medical record) dated 5/16/23, included delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain) major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 as…
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 · D2023-05-18 · 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 a gradual dose reduction (GDR) was attempted or an adequate medical justification for the use of psychoactive medications for 1 of 5 residents (R19) who was reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnosis (identified on the physician order sheet in the medical record) dated 5/16/23, included; delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain), major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · 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 dental needs were comprehensively assessed and appropriately acted upon (i.e., referred to a dental provider) for 2 of 2 residents (R33, R5) reviewed who voiced dental concerns. Findings include: R33's quarterly Minimum Data Set (MDS), dated [DATE], identified R33 had moderate cognitive impairment, demonstrated no delusional behavior or rejection of care, and required extensive assistance with personal hygiene (i.e., combing hair, teeth brushing). Further, R33's Census listing, printed 5/18/23, identified R33's current payer as, Medicaid. R33's care plan, dated 3/2023, identified R33 had an activities of daily living (ADL) self-care deficit and listed several interventions for R33 including, ORAL CARE: Limit assist with oral cares, and, Oral examination per protocol and for complaints of mouth pain/discomfort by staff nurse. On 5/15/23 at 3:51 p.m., R33 was observed while seated in their wheelchair. R33 was interviewed at this…
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.
- No harm found · C2024-06-05 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 48 residents who resided at the facility. Findings include: Review of the Payroll Based Jouranal (PBJ) Staffing Data Report, submitted for the first quarter of 2024 (October 1-December 31), identified no RN hours for the following dates: 10/21/23, 10/22/23, 12/3/23, 12/26/23 and 12/31/23. Review of the facility staffing schedules with the dates identified above, 2/24, 3/24, 4/24, 5/24 weekends and holiday staffing schedules. These schedules identified the following dates with no RN hours on 3/24/24 and 5/27/24. During interview on 6/05/24 at 9:46 a.m., staffing coordinator (SC)-E verified she does the nursing schedules for the facility. SC-E verified there the expectation was to have a RN in the facility every day for at least 8 consecutive hours. SC-E verified there was no RN working the following days: 10/21/23 10/22/23 12/3/23 12/16/23 3/24/24 5/27/24 SC-E stated the RN coverage has gotten…
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
$25,378 in federal fines across 1 penalty.
- $25,378 — penalty dated 2026-05-08
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROBST, SETH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/01/2024 |
| FAIRBAIRN, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2024 |
| MOHLIN, JAMIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2024 |
CMS files one row per role, so the 7 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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 245445. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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.