Tweeten Lutheran Health Care Center

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

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.

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.

53.4% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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.

Staffing

How full it usually is: this home is certified for 49 beds and averages 35.6 residents a day — about 73% occupied, or roughly 13 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 0.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.16 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.53 is below 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 0.76 hrs/resident/day on weekends vs 1.02 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.16 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 81% is well above 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 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.

37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · J2026-06-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 notify the physician of hypoglycemic (low blood sugar) episodes, ensure insulin was safely administered, and provide rescue medication per facility protocol during a severe hypoglycemic episode for 1 of 4 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a severe hypoglycemic episode after repeated hypoglycemia episodes earlier in the day and was subsequently found unresponsive and required emergency medical care and hospitalization. In addition, the facility failed to notify the physician immediately of hypoglycemic episodes for 2 of 4 residents (R1, R2). The immediate jeopardy (IJ) began on 5/15/26 when it was identified that R1 had hypoglycemic episodes during the day, continued to receive insulin, proceeded to have a severe hypoglycemic episode, and needed to be hospitalized . On 6/5/26 at 4:32 p.m., the administrator and infection control/quality nurse (IC-Q) were notified of the IJ. The IJ was removed on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Immediate jeopardy · J2025-07-18 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure insulin was safely administered by following the rights of medication administration prior to administering insulin for 2 of 4 residents (R1 and R2). This resulted in an immediate jeopardy for R1 who required hospitalization for blood glucose monitoring and intravenous dextrose (sugar solution) to return to baseline, and a likelihood of serious harm for R2. The immediate jeopardy (IJ) began on [DATE] when licensed practical nurse (LPN)-A injected R1 with 40 units of rapid-acting insulin instead of the prescribed 40 units of long-acting insulin, resulting in R1 being sent to the emergency room (ER) for monitoring and treatment of severe hypoglycemia (low blood sugar). The administrator and interim director of nursing were notified of the IJ on [DATE] at 5:37 p.m., which was identified at the scope and severity of J, ISOLATED. The IJ was removed on [DATE] at 12:18 p.m., but non-compliance remained at the lower scope and severity 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 monitor, comprehensively assess, and develop and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R4) reviewed for pressure ulcers. Findings include:R4's face sheet dated 12/19/25, identified diagnoses of dementia (a severe decline in mental abilities) and Parkinson's Disease (a progressive brain disorder leading to movement issues like tremors, stiffness, and slowness).R4's skin risk assessment with Braden (a healthcare tool for pressure ulcer risk) dated 9/8/25, identified R4 was not at risk for pressure ulcers.R4's Annual Minimum Data Set (MDS) dated [DATE], identified R4 received hospice services, needed maximum assistance for bed mobility/transfers, at risk for pressure ulcers, had one stage one pressure ulcer and had moderately impaired cognition.R4's pressure ulcer focus care plan dated 12/8/23, identified R4 was at risk for pressure injury related to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to immediately respond to elopement when 1 of 1 resident (R1) activated an exit alarm and walked outside off the facility property without appropriate clothing for temperature of 1 degree/windchill of -7 degrees. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 1 of 3 residents (R8) reviewed for accidents.Findings include:R1's face sheet dated 12/18/25, identified diagnosis of mild cognitive impairment, chronic kidney disease (condition where kidneys have been damaged), and history of neoplasm (cancer) of the breast.R1's progress note dated 12/2/25, identified R1 had been admitted and had a history of wandering out of her home and nursing aware that if R1 needed to be admitted to the secured memory care unit this can be done. R1's elopement evaluation dated 12/2/25, identified R1was ambulatory,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a comprehensive nutritional assessment was completed and further failed to identify, comprehensively assess and monitor for signs/symptoms of dehydration for 1 of 3 residents (R1) reviewed for change in condition. The facility's failures resulted in harm when R1 required a 3 day hospitalization for profound hypernatremia and hypovolemia. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of congestive heart failure, hypernatremia (a condition where there is too much sodium in the blood that can be caused by diarrhea and not drinking enough fluids) and hyperosmolality (a condition where the blood has a high concentration of salt, glucose and other substances which draws water out of the body's organs). R1 was always continent of bowel and bladder with no special diet. R1 received diuretics. R1's order summary dated 10/8/24, identified R1 had an order to receive torsemide…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-08 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 investigate immediately a cause of hypoglycemia (low blood sugar) for 1 of 4 residents (R1) reviewed for insulin administration. Findings include:R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included:Administer medications per physician orders. Nursing staff will dispense and administer all medications.Monitor blood sugars per physician orders.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-06-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 nurses were competent in their skill level to identify a hypoglycemic (low blood sugar) episode and safely administer insulin for 1 of 1 resident (R1) reviewed for insulin administration. Findings include: R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included: Administer medications per physician orders. Nursing staff will dispense 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-06-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record for 2 of 3 residents (R1, R2) who were noted to have missing blood sugar values in their record. Findings include:R1R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, and hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included: -Administer medications per physician orders. Nursing staff will dispense and administer all…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · F2026-04-02 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set 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 (QAPI) committee identified, investigated, analyzed, and responded high risk issues related to pressure ulcers by developing and implementing action plans for process improvement. This deficient practice had the potential to affect all 33 residents that resident in the facility. Review of QAPI minutes from December 2025 through March of 2025 identified across all months the facility consistently collected and reported data related to pressure ulcers; however, the documents did not address or include root cause analysis, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, and monitoring if interventions for effectiveness. Quality documents included the following: The December QAPI meeting demonstrated the facility had a process for collecting and reporting quality data across multiple departments. Specific measures were identified, including 2 bruises and a medication error involving…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-02 · tag F0561 — failed to honor residents' choices — isolated
  Honor 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide resident preference for positioning for 1 of 1 resident (R4) who was reviewed for pressure ulcers. Findings Include:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but is able if prompted or given times. R4 has unclear speech, with slurred or mumbled words. R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue,…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-02 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  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 timely provide the required liability and appeal rights notices prior to discharge from Medicare Part A services for 1 of 3 residents (R40) reviewed for beneficiary notices.R40's last day of covered Medicare Part A Skilled Services was 3/4/26, as identified on the form CMS-20052 (SNF [skilled nursing facility] Beneficiary Protection Notification Review). The form also indicated the faciilty/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. Section 2 indicated the Notice of Medicare Non-Coverage (NOMNC, form CMS-10123) was not issues because Resident discharge immediately after LCD.R40's progress notes dated 2/26/26 recorded as a late entry on 3/2/26 indicated a last covered date from physical therapy on 3/2/26 and occupational therapy on 3/3/26 with R40 discharging home 3/4/26. On 3/3/26 the progress notes indicated R40's family will arrive on 3/4 to bring R40 home on discharge. On 3/4/26 progress…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-02 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to obtain careplanned baseline side effect monitoring for 1 of 2 residents (R15) reviewed for antipsychotic medication use.Findings include: R15's face sheet indicated an admission date of 10/17/25. R15's quarterly Minimum Data Set (MDS) dated [DATE] indicated R15 was moderately cognitively impaired however could not complete the assessment. R15 also exhibited fluctuating disorganized thinking with daily behaviors not directed at others. The MDS also indicated R15 takes antipsychotic (medication used to treat mental health conditions), antianxiety, and antidepressants. R15's diagnoses included vascular dementia with moderate psychotic disturbances, psychotic disorder, and non-traumatic brain dysfunction.R15's medication administration record indicated R15 received olanzapine (antipsychotic medication) 5 milligrams (mg) every morning from admission [DATE]) until 10/19/25. From 10/20/25 until 11/5/25 R15 received Olanzapine 5 mg twice a day.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 2 of 2 residents (R4, R24) reviewed for pressure ulcers. Findings include: R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue, usually over bony prominences, caused by prolonged pressure, friction, or shear). R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to follow manufacturer's instructions for safe operation of mechanical sit-to-stand lift and/or implement policies to ensure safety and supervision while attached to a sit-to-stand lift for 1 of 1 (R20) resident reviewed for lift safety.Findings include:R20's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R20 had no hearing impairment, speech is clear and intelligible, ability to understand others, and moderate cognitive impairment. Additionally, R20 was dependent on staff for toileting, dressing, and positioning from sitting to standing and chair to bed.R20's care plan dated 2/6/26 stated R20 has limited mobility with interventions including:-assist of 1 staff for transfers using EZ Stand (brand of sit-to-stand mechanical lift) for all transfers, XL harness, do not use leg strap per resident request-informed of risks vs. benefits, resident voiced understanding Additionally, R20's care plan dated 2/6/26 stated R20 was a risk…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R4) who was at risk for dehydration had hydration available and within reach.Findings include:Findings include:R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue, usually over bony prominences, caused by prolonged pressure, friction, or shear).R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

• Medicare payment denial — starting 2024-12-28 for 5 days

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

CMS files one row per role, so the 31 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $91K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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