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Stewartville Care Center

120 Fourth Street Northeast, Stewartville, MN 55976 · Non profit - Corporation · 50 certified beds · (507) 533-4288 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0744)2 actual-harm citations$11,911 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $11,911 in federal fines (most recent 2023-09-01)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
208 Center Town Plaza North, 3rd St NE · (507) 533-4727 · Call to confirm hours
Pharmacy
220 Center Town Plz N · (507) 533-4245 · Call to confirm hours
Grocery
1500 2nd Ave NW · (507) 533-7786 · Call to confirm hours
Park
305 Lakeshore Dr · (507) 533-4745 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.1%18.2%15.4%worse
Long-stay residents who lose too much weight7.0%4.1%5.4%worse
Long-stay residents with a catheter left in their bladder10.1%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection6.7%2.6%2.0%worse
Long-stay residents with depressive symptoms1.0%4.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.0%4.0%3.3%worse
Long-stay residents whose ability to walk worsened34.8%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication2.3%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%96.1%95.3%typical
Long-stay residents with pressure ulcers5.2%5.2%4.7%typical
Long-stay residents with worsening bladder/bowel control41.3%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.8%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.5%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine84.6%82.7%79.4%typical
Short-stay residents rehospitalized after admission15.8%23.5%22.6%better
Short-stay residents with an outpatient ER visit17.1%14.8%12.0%worse

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.

58.9% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.9%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
45.8%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 45.8% 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 24 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 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.9%CMS range 42.5–72.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.3–16.210.7%Oct 2022–Sep 2024no 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 discharge45.8%56.6%Oct 2024–Sep 2025CMS 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 discharge45.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge29.2%50.0%Oct 2024–Sep 2025CMS 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 identified91.7%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.9–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS 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

0.89
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.68
Aide hours/ resident / day
4.36
Total nurse hours/ resident / day
0.39
RN hoursweekends
60.3%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 42.7 residents a day — about 85% occupied, or roughly 7 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 4.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 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 3.78 hrs/resident/day on weekends vs 4.60 on weekdays — 18% thinner on weekends. RN hours go from 1.09 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% 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

6
deficiencies at the latest standard inspection (2026-06-18)
6
at the previous standard inspection (2025-04-03)

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.

ABCDEFGHIJKL

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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2026-04-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 observations, interviews, and document review, the facility failed to protect a resident's right to be free from verbal abuse for 1 of 3 residents (R4) when R1 who had a history of cognitive impairment, personality changes, impulsiveness, and making poor choices, repeatedly yelled at R4, made a threat to shoot him in the head, and entered his room on three different occasions.Findings include: R4's admission minimum data set (MDS) dated [DATE], he was cognitively intact, no depression or behaviors. He was occasionally incontinent with bowel movements and frequently incontinent with urination. His care areas triggered activities of daily living, urinary incontinence, falls, and pressure ulcers. R4's care plan dated 1/15/26, indicated he had polyneuropathy (nerves to the arms and legs are damaged causing numbness, tingling, pain, and weakness), repeated falls, heart issues, pain in the right hip and knees, weakness, and lower back pain. He needed assistance with the toilet, bathing, grooming, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-06-12 · 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 implement care planned fall interventions for 1 of 2 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who had an unwitnessed fall while self-transferring when the motion sensor alarm did not sound and failed to alert staff that R1 was self-transferring as intended per care plan. Additionally, the facility failed to determine why the motion sensor alarm did not alert staff following the fall and added a second alarm. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety, and depression with severe cognitive deficits. R1 used a wheelchair and walker, was frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and was at risk for falls…

    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 before2026-06-18 · tag F0554 — isolated
    Allow 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 resident assessment to self-administer medications, was implemented and followed consistently in accordance with physician orders for 1 on 1 resident (R8) reviewed for self-administration of medications.Findings include: R8's comprehensive Minimum Data Set (MDS) assessment, dated 5/11/26, identified R8 had impaired cognition and required extensive assistance with activities of daily living(ADL) and maximal assistance with mobility. R8's care plan dated 05/04/26 indicated, resident would like to administer oral medications and be more independent with ADL's. Resident was unable to self-administer safely medications, may self-administer inhalers/nebs after set up only. R8's active medications list review included an order for R8 to self-administer inhalers and nebulizer treatments only after set up by staff and could not self-administer oral medications safely dated 11/09/23. R8's self-administration of medication assessment dated…

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

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-18 · 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 ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to 1 of 3 residents (R27) reviewed for beneficiary notices.Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition. R27's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 2/15/26. R27's NOMNC form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 2/14/26. The form was signed by the resident dated 6/15/26. Additionally, R27's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 5/23/26. R27's NOMNC form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 5/23/26. The form was signed by the resident dated 6/15/26. During an interview on 7/1/25 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.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-18 · 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 interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 3 resident (R4, R1) reviewed for hospice care and smoking. Findings Include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired. R4's diagnosis included dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) with moderate agitation During record review on 6/16/26 at 10:01 a.m., noted R4 was admitted to hospice on 1/30/26. R4's comprehensive care plan failed to include a resident-specific hospice care plan, including hospice diagnosis, hospice provider information, and resident choices and preferences. During an interview on 6/16/26 at 1:24 p.m., registered nurse (RN)-A stated she is unsure why R4 was put on hospice, probably due to his infections or maybe his worsening dementia. RN-A stated she didn't know what end-of life preferences R4 had.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-18 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 provide supervision to 1of 1 resident (R8) reviewed for activities of daily living who was left unattended on the toilet for more than 1 hour. Findings Include: R8's comprehensive Minimum Data Set (MDS) assessment, dated 5/11/26, identified R8 had impaired cognition and required extensive assistance with activities of daily living and maximal assistance with mobility. R8 's care plan dated 5/4/26 indicated, resident had a history of falling related to impulsiveness and perceived abilities. Motion sensor alarm to monitor movements due to unattended / unassisted transfers resulting in falls, reminders to use call light for all transfers. Record review indicated R8's had an unwitnessed fall on 6/12/26 at 10:06 a.m., in the bathroom, right beside the toilet and the wheelchair. R8's head was found leaning against the corner of the doorway. During an observation on 6/16/26 9:03 AM, R8 was assisted onto the toilet by nursing assistant (NA)-A. At 9:40 a.m., R8 was observed sitting on the toilet, chin to chest,…

    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 no plan of correction
  • Potential for harm · D2026-06-18 · 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 complete weekly wound assessment and documentation for 1 of 1 resident (R6) reviewed for pressure Ulcer/Injury who had 2 unhealed stage 4 pressure ulcers (full-thickness skin and tissue loss, exposed bone, ligament, cartilage, or muscle) on bilateral buttocks. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. Findings Include:R6's quarterly Minimum Data Set (MDS) assessment, dated 6/3/26, identified R6 had intact cognition and was dependent on staff for activities of daily living and mobility. MDS identified two stage 4 pressure ulcers, pressure reducing device for bed, chair and application of nonsurgical dressing and ointment.R6's diagnoses included stage 4 pressure on right and left buttock, hereditary spastic paraplegia (inherited disorders that cause progressive stiffness and weakness in the legs, often leading to mobility challenges).R6's care plan dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-06-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 interview and record review the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R37) reviewed for pharmacy services. Findings include: R37 face sheet indicated R37 admitted to the facility on [DATE]. R37's admission Minimum Data Set (MDS) assessment, dated 6/9/26, indicated R37 was cognitively intact with no delirium and no behaviors. R37 had upper and lower body impairment and required assistance with all activities of daily living. The MDS also indicated R37 had diagnoses of anxiety and depression. R37's diagnoses list included heart disease, major depressive disorder, and generalized anxiety disorder. R37's care plan indicated R37 received an antianxiety medication related to anxiety disorder.R37's hospital discharge orders dated 6/3/26, indicated clonazepam (prescribed to treat anxiety)0.5 mg tablet give 1/2 tablet twice a dayR37's Medication Administration Record (MAR) indicated R37 had an order for clonazepam 0.5 mg tablet. Give 1/2…

    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 no plan of correction
  • Potential for harm · D2025-12-04 · tag F0700 — isolated
    Try 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 identify alternatives prior to installing or using grab bars (bars installed at the head of the bed for a resident to hold onto for bed mobility or transfers), ensure grab bars were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of grab bars for 2 of 3 residents (R3, R4) who were observed to have grab bars on their bedsR3's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses included Type 2 diabetes and chronic heart failure.R3's care plan dated 6/16/25 indicated R3 was independent with bed mobility and utilized bilateral grab bars.R3's Informed Choice Consent for Assistive Devices dated and signed 11/17/23 indicated risks and benefits were discussed and consent obtained from R3 for bilateral grab bars. R3's electronic health record (EHR) lacked evidence a grab bar assessment had been completed 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
  • Potential for harm · E2025-04-03 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, interview, and record review, the facility failed to ensure discontinued medications were returned to the pharmacy or destroyed in a timely manner to decrease the potential for drug diversion for 1 of 1 medication rooms. Findings include: During an observation and interview with Licensed Practical Nurse (LPN)-A on 4/2/25 at 11:00 a.m., the shelf in the medication room had 108 cards of varying oral medications including blood pressure medications, supplements, antidepressants, etc. There were also two plastic bins with varying creams, bulk powdered medications, bottled liquid medications, boxes of insulin pens, and IV (intravenous) antibiotic medications. These medications included: -One unopened box of 5 glargine insulin pens dated 12/8/24 and an unopened box of 5 aspart insulin pens dated 1/2/24 for R39. -Ten medicine balls of intravenous cefazolin (antibiotic) dated 1/13/25 for R92, two unopened bottles of liquid Haldol (antipsychotic medication used to treat mental health disorders) containing 15 ml (milliliters) and 30 ml's liquid medication dated 3/4/25…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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

    Based on observation, interview, and document review, the facility failed to ensure meals were served warm/hot and palatable to promote quality of life and nutritional intake for 2 of 2 residents (R16 and R29) reviewed for dining. This had the potential to affect all residents who received food from the kitchen. Findings include: During an observation on 4/02/25 at 7:07 a.m., the cook (C)-A was preparing breakfast, food observed on the heat table included oatmeal, malt-o-meal, ham, and western style eggs. Toast was sitting above the steam table on a metal baking sheet. 4/02/25 at 7:34 a.m., plating begins for the residents seated in the dining room, C-A stated meals are served to dining room first then resident who prefer a tray in their rooms. 4/2/25 at 8:15 a.m., plating begins for East wing, trays put inside transport cart and delivered, last tray delivered to R16 in the East wing 4/2/25 at 8:22 a.m. 4/2/25 at 8:36 a.m., plating begins for North wing, trays put inside transport cart and delivered. 4/2/25 at 8:47 a.m., plating begins for [NAME] wing; extra tray added to transport…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 40 residents, staff and visitors who received food from facility kitchen. Findings include: During the initial kitchen tour on 3/31/25 at 11:35 a.m., dietary manager (DM) stated the dates listed on the food was the date of opening or when it was prepped and should be tossed after one week. The following items were observed in the fridge or dry storage with expired or undated food: -Hot dogs dated 3/16/25 -Bratwurst dated 3/17/25 -Tuna Salad dated 3/15/25 -Clam chowder dated 2/25/25 -Cranberry preparation date 3/19/25 -Celery preparation date 3/1925 -Corn preparation undated -Ground all spice, manufacturer expiration date 7/19/24 -Ground Cloves, manufacturer expiration date 9/5/24 During interview on 4/2/25 at 9:11 a.m., cook (C)-A and dietary aide (DA)-A stated the date on foods in the fridge are the dates they were open or prepped on. C-A and DA-A both…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2025-04-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 utilized for 5 of 5 residents (R23, R6, R15, R21, R36) reviewed for enhanced barrier precautions (EBP). Findings include: R23's face sheet printed 4/2/25, included diagnoses of chronic pain, artificial hip joint, weakness, and fistula of intestine. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, upper and lower extremity impairment, use of a wheelchair, substantial/maximal assistance with toileting hygiene, upper and lower body dressing. R23's care plan revised 1/5/24, indicated extensive assist with bathing, grooming, and dressing. R23's care plan further indicated incontinence of bowel and presence of nephrostomy (opening between kidney and the skin) for urination. R6's face sheet, included diagnoses of history of traumatic brain injury, benign prostatic hypertrophy (enlargement of prostate gland causing…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This had potential to affect all 40 residents, staff and visitors who consumed meals from the main production kitchen. Findings include: During interview on 4/2/25 9:11 a.m., cook (C)-A stated the left side of the plate warmer does not work, only plates on the right side get warm. C-A stated the left side had not functioned for some time. C-A stated she told the dietary manager (DM) a while ago, but the left side of plate warmer is still broken. C-A stated the broken plate warmer was a concern because the warmed plates help the food stay warmer longer. Food that is placed on the cold plates from the left side of the plate warmer cools faster and residents become unhappy when they eat cold food. During interview on 4/2/25 1:47 p.m., administrator stated the facility does not have or keep maintenance logs for the kitchen plate warmer. Administrator stated if dietary had a problem with the plate warmer, they should call maintenance and if maintenance can't…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · 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 (R6) reviewed for nutrition and weight loss had received a supplement to increase calorie intake and weight per provider order. Findings include: R6's face sheet included diagnoses of history of traumatic brain injury, weakness, pain, surgery of the digestive system, vascular disorder of the intestine, ischemic colitis (reduced blood flow to the colon), intestinal obstruction, and dysphagia (difficulty swallowing foods and liquids). R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no behaviors or rejection of care, use of a wheelchair, substantial/maximal assistance with toileting hygiene, bathing, dressing, and personal hygiene. R6's care plan revised 1/31/25, indicated history and risk of dehydration, thickened liquids, risk for aspiration related to traumatic brain injury and postural positioning, poor safety awareness related to eating, pureed…

    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 · D2024-12-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise the comprehensive care plan for diabetic management that included goals and individualized interventions for 2 of 3 residents (R1, R2) reviewed for diabetic management. Findings incude: R1's face sheet identified R1 had diagnoses that included type 1 diabetes mellitus (autoimmune disease where the pancreas fails to produce insulin) with hyperglycemia (high blood sugar), unspecified diabetic retinopathy (diabetic complication that leads to vision loss) without macular degeneration, other diabetes complications unspecified, hypoglycemia (low blood sugar) without coma. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had verbal behaviors directed at others that occurred 1 to 3 days, did not reject cares, and had insulin injections daily. R1's lab report dated 4/9/24, identified a hemoglobin A1C (blood test that measures the average amount of sugar in the blood for over the past few months) result was 8.6 which…

    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 · D2024-06-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to report an unwitnessed fall with injury to the state agency (SA) for 1 of 2 residents (R1) reviewed for falls. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy and physical therapy; all transfers & ambulation-SBA (stand by assist) with four wheeled walker, due 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate an unwitnessed fall with a serious injury for 1 of 2 residents (R1) whose motion sensory alarm did not sound/alert staff of movement and R1 fell. This resulted in rib fractures and contusions to R1's face. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy…

    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 date of correction
  • Potential for harm · D2024-06-12 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 assess, develop and implement a person centered dementia care treatment plan for 1 of 2 residents (R1) reviewed who had Lewy body dementia, was startled easily, at risk for falls, and the facility added a pressure sensor alarm to R1's bed, which sounded in her room. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel and had no falls since admission. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program 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
  • Potential for harm · F2024-05-24 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutritional service. This had the potential to affect 45 of 45 residents who resided in the facility. Findings include: During an interview on 5/24/24 at 9:12 a.m., [NAME] (C)-A, indicated the previous DM walked out earlier this month and the regional manager quit in April (2024). C-A had been doing the orders and the schedule for the past week. During a clarifying interview on 5/24/24 at 12:30 p.m., C-A stated she has not had any formal training for DM position and there was [NAME] currently in training for that position. C-A further stated the facility's registered dietician (RD), does not come into the kitchen when the RD is at the facility and has not been providing any support since the DM walked out. C-A could not articulate when RD was last at the facility. During an interview on 5/23/24 at 7:00 p.m., the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 safe food storage and kitchen cleanliness to reduce and/or prevent the risk of food borne illness. This had the potential to affect 45 of 45 residents whop obtained their meals from the kitchen. Findings include: During the initial kitchen tour with cook (C)-B on 5/23/24 at 5:23 p.m., the following was observed: General kitchen area: The kitchen floor was noted to have a black thick dry substance arround the all the legs of prep tables and cabinents. The wall, floor, and piping underneath the dishwasher had adheared dry substances varying in size and color. C-B verified the presence of soiled areas on the floor/base boards and pipes. C-B stated he was unsure when the last time those areas were last cleaned and they should be cleaned. The cabinents that contained clean pans had white subsance and food crumbs. The ice machine had a white thick substance along the bottom of the machine with several towels underneath. C-B was not aware of when the ice machine was maintainenced and was not sure why 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 therapeutic diet per physician's orders were followed for 1 of 3 residents (R1) reviewed for therapeutic diets. Finding include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 had intact cognition with the diagnoses that included chronic kidney disease stage 3b, functional dyspepsia-indigestion, and moderate protein-calorie malnutrition. R1 was on a therapeutic diet and had no weight gain or loss noted. R1 required set up only with eating and oral hygiene. R1's physician orders included the following: -Diet: renal dialysis (2000 milligrams (mg) sodium, 100 grams (GM) protein, 2700 mg potassium, low phosphorous (start date 10/27/23). During a kitchen observation and interview on 5/23/24 at 4:45 p.m. dietary menus were reviewed with cook (C)-B. The menu identified for regular diets the following items would be served for the evening meal: Hawaiian baked ham, seasoned green beans, baked sweet potatoes, corn bread,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-11 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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, interview, and document review, the facility failed to ensure controlled substances were stored and destroyed in a timely manner to prevent potential diversion. In addition, the facility failed to ensure prescribed medications were secure at all times to prevent potential diversion and/or ingestion. Findings include: Controlled Medications During an observation and interview on [DATE] at 3:08 p.m., of the mediation storage room, LPN-B stated controlled substances waiting to be destroyed are locked in DON's office. Count is verified with another nurse, 'to DON office' is written on count sheet in bound book, and then signed by both nurses. The DON then places the medication in a locked file cabinet in her office. During an interview on [DATE], DON stated controlled substances waiting for destruction are kept under double lock in a file cabinet in her office. A single lock file cabinet was observed under a desk in DON's office. DON opened the file drawer, revealing medications waiting for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure community use glucometer's were properly cleaned and disinfected between patient use and complete hand hygiene for 3 of 3 residents (R10, R34, R36) observed to have their blood glucose checked with the devices. This had the potential to affect 9 of 9 residents R6, R8, R10, R15, R18, R31, R34, R36, and R39 identified in the facility with orders to obtain blood glucose monitoring. Findings include: Per manufacturer's instructions for use of the Arkray Assure Platinum Blood Glucose Monitoring System in Section B: To reduce the chance of infection, the clinician is to, Wash hands thoroughly with soap and water before putting on a new pair of gloves and performing the next patient test. Guidelines for cleaning and disinfecting the unit reads, To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed. Per the manufacturer's instructions, the clinician is to utilize the approved and recommended Environmental Protection Agency (EPA)-registered wipe…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, interview, and record review, the facility failed to ensure dignity for 1 of 1 resident (R2) when yelling out resident's name and care information in public areas. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicates R2 is dependent on staff for feeding and activities of daily living, and mild cognitive impairment. R2 has diagnosis of contracture (stiffness with immobility) of multiple sites, vitamin B12 deficiency, mild cognitive impairment. R2's physician orders dated 1/8/24 indicate R2 receives cyanocobalamin (vitamin B12) injection daily. During an observation on 1/9/24 at 11:54 a.m., RN-A stood at medication cart near the lobby common area and asked RN-C, who was seated at the nurse's station, to help hold [R2's first name] to give medication injection. RN-C turned to LPN-B, who was at the other end of the nurses station and asked can you help hold [R2's first name]. RN-A looked at surveyors stating, I didn't say her last name. During interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a resident who had been assessed to not self-administer medication, did not self-administer medication and store medications in the residents room for 1 of 1 residents (R9). Findings include: R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R9 had impaired cognition along with vision impairment. Diagnoses included total retinal detachment (retina, part of eye, is pulled away from its normal position), vitreous hemorrhage, left eye (blood within the eye), and cerebral infarction (stroke). On 1/8/24, at 1:15 p.m., R9 was ambulating independently in her room with a cane. She seated herself in her wheelchair. There was a nightstand with shelves along the wall right next to her bed. The bottom shelves are within reach of R9 while seated in her wheelchair. On the first shelf of the nightstand, R9 had a tube of opened Biofreeze pain relief gel, Systane Original eye drops, Nasal moisturizing spray and Nasal…

    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 · D2024-01-11 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 maintain confidentiality of resident's personal and medical records when staff left the computer open allowing others to view the electronic medical records (EMR) and shift report notes lay open on top of the medication cart. Findings include: During an observation on 1/9/24 at 11:54 a.m., RN-A dispensed R2's medication and walked away with R2's medical information still visible on the EMR. During an observation on 1/9/24 at 12:15 p.m., a computer located on the north medication cart was left unattended with medical information visible to anyone walking by. RN-C was seated at the nurses' station with medication cart and computer facing away from her. RN-A was at a different medication cart and made aware information was visible. RN-A did not lock computer screen. Director of nursing (DON) was updated and verified the computer was left open. During an observation on 1/9/24 at 12:32 p.m., RN-C dispensed R142's medication, locked medication cart, and walked to resident's room to administer medications. EMR was…

    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 · D2024-01-11 · 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 observation, interview, and document review, the facility failed to ensure licensed nurses have the competencies necessary to administer medications through g-tube (gastrostomy-tube in stomach used for administration of medications and liquid tube feeding), troubleshooting complications, and ensuring documentation of findings for 1 of 1 resident (R2) reviewed for tube feeding. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicates R2 is dependent on staff for eating, has active diagnosis of malnutrition, and receives tube feeding and mechanically altered diet. R2 has a diagnosis of severe protein-calorie malnutrition, gastrostomy (surgical hole in stomach that feeding tube is passed through), and oral dysphasia (unsafe swallowing) R2's care plan dated 5/4/22, indicates R2 receives liquid nutrition by g-tube as well as pleasure feedings of pureed foods and thin liquids. R2's physician orders dated 1/8/24 indicate R2 has a 12 French (size of tube) feeding tube, flush…

    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 date of correction
  • Potential for harm · D2024-01-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 interview and document review, the facility failed to act upon the consultant pharmacist ' s recommendation for 1 of 6 residents (R1) reviewed for unnecessary medications. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 with significantly impaired cognitive decision making, dependent on staff for all assist of daily living (ADL's) and taking antipsychotics on a routine basis. In addition, R1 with diagnoses of Alzheimer's, visual hallucinations, and dementia. R1's physician orders (PO) with start date of 9/5/23 indicate R1 ordered for Seroquel (quetiapine- Antipsychotic) 12.5mg (milligrams) every Monday morning. In addition, PO dated 11/28/23 with order for Seroquel (quetiapine) 37.5mg twice per day. Both PO's did not have a diagnoses associated with the medication orders. During interview with director of nursing (DON) on 1/11/24 at 9:24 a.m., DON reviewed R1's electronic medical record (EMR) for R1 and verified there was no diagnosis for the use of Seroquel.…

    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
  • Potential for harm · D2024-01-11 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 routine dental care for 1 of 1 (R2) resident reviewed for dental services. Findings include: R2 admitted to facility on 6/19/2020 with diagnoses of contracture (a condition of shortening and hardening of muscles and tendons leading to deformity of joints) of left and right hand and mild cognitive impairment. MDS indicators indicate R2 is dependent on staff for oral and personal cares and has mild cognitive impairment. Dental was not recently assessed. R2's Dental care plan dated 5/4/2022 indicates resident has own teeth, in poor condition and will be screened annually. R2 receives nutrition via tube feeding and requires R2 to have thorough oral cares. R2 Care conference notes dated 10/26/23, indicated resident has own teeth and sees a dentist. During an interview on 1/8/2024 at 4:43 p.m., FM-A stated R2 is no longer able to brush her own teeth and R2's teeth look like they are going to fall out. During observation and interview 1/10/24 at 10:22 a.m., R2 stated she would like to brush her teeth 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.

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$11,911 in federal fines across 1 penalty.

  • $11,911 — penalty dated 2023-09-01

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 / managerTypeRoleSince
EVANS, JACKIEIndividualCORPORATE DIRECTORsince 03/01/2023
GRISIM, CONNIEIndividualCORPORATE DIRECTORsince 09/01/1986
HONSEY, DANIELIndividualCORPORATE DIRECTORsince 09/27/2023
JONES, JARETTIndividualCORPORATE DIRECTORsince 03/01/2016
LASSIG, SARAIndividualCORPORATE DIRECTORsince 03/01/2024
NELSON, MARGARETIndividualCORPORATE DIRECTORsince 09/01/1986
NOGOSEK, JENNIFERIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2023
ZIMMERMAN, DANIELIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2023
FEIJO, LAURIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/09/2024
HOESING, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/13/2011
LAMMERS, LAURENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/06/2019
NEUZIL, CAROLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2007
SWANTON, KRISTINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2012
WILLIAMS, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/06/2025
WUERFLEIN, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/07/2007
CITY OF STEWARTVILLEOrganizationADP OF THE SNFsince 10/20/1969

CMS files one row per role, so the 27 rows in the source record cover these 16 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.

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

Follow the money — this home’s finances

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

$6.2M
Net patient revenuemost recent cost report
+4.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 57%Medicare 7%Other / private 36%

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

$383per resident / day
operating cost
$11,653per month
≈ monthly operating cost
$401per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Minnesota
$10,646/mo
Nursing home (semi-private)
$13,870/mo
Nursing home (private)
$6,573/mo
Assisted living

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 245349. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-18, 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.

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