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The Estates At Greeley LLC

313 South Greeley Street, Stillwater, MN 55082 · For profit - Limited Liability company · 64 certified beds · (651) 439-5775 Medicare & Medicaid certified

Call the home — (651) 439-5775 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Mar 2025Behavioral-health or dementia-care citations — no harm found (F0740, F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1500 Curve Crest Blvd W · (651) 439-1234 · Call to confirm hours
Pharmacy
1500 Curve Crest Blvd W · (651) 430-4670 · Call to confirm hours
Grocery
101 Owens St N · (651) 439-3515 · Call to confirm hours
Park
W Ramsey St · (651) 296-6157 · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 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 rating3★
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 increased12.9%18.2%15.4%better
Long-stay residents who lose too much weight5.3%4.1%5.4%typical
Long-stay residents with a catheter left in their bladder1.9%1.9%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.8%2.6%2.0%worse
Long-stay residents with depressive symptoms14.8%4.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%4.0%3.3%typical
Long-stay residents whose ability to walk worsened20.4%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.9%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers3.6%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control31.0%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.9%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%1.9%1.4%typical
Short-stay residents given the seasonal flu vaccine77.3%82.7%79.4%typical
Short-stay residents rehospitalized after admission23.5%23.5%22.6%typical
Short-stay residents with an outpatient ER visit19.4%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.

54.9% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.9%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
43.1%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 43.1% 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 58 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF54.9%CMS range 45.6–64.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 5.7–13.110.7%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 discharge43.1%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 discharge39.7%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 discharge48.3%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 identified68.6%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay2.9%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 worsened4.3%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 hospitalization6.1%CMS range 2.9–13.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.90
RN hours/ resident / day
0.59
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.53
RN hoursweekends
54.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 53.6 residents a day — about 84% occupied, or roughly 10 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.91 hrs/resident/day on weekends vs 3.46 on weekdays — 16% thinner on weekends. RN hours go from 1.05 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-07-02)
8
at the previous standard inspection (2024-08-07)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2024-06-25 · 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 accurately transcribe an order for an anti-convulsant (anti-seizure medication) upon admission for 1 of 3 (R1) residents reviewed for medication administration in accordance with physician instructions. This resulted in actual harm for R1 when he had seizures and required treatment in the hospital. The facility had taken action to prevent this type of medication error from occurring again, therefore is being cited at past noncompliance. Findings include: R1's facesheet dated 6/25/24, indicated R1 was admitted on [DATE] from an acute care hospital with diagnoses including generalized idiopathic epilepsy and epileptic syndromes not intractable without status epilepticus (a seizure disorder). R1's hospital Medicine History & Physical dated 6/4/24, noted R1 had a history of epilepsy and cognitive disorder. It identified a diagnosis of generalized convulsive epilepsy with a plan to continue with home dosing of 1250 mg [milligrams] BID [twice…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2026-07-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure physician-ordered passive range of motion (ROM) exercises were completed for 1 of 2 residents (R6) reviewed for range of motion.Findings include:R6's quarterly Minimum Data Set (MDS), dated [DATE], indicated R6 had moderate cognitive impairment. Diagnoses included cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side following a cerebral infarction (blocked blood vessels that deprived part of the brain of oxygen and nutrients). The MDS indicated R6 was dependent on staff for mobility. The MDS also indicated a restorative nursing program had not been completed.R6's physical therapy order, dated 3/31/26, directed staff to complete passive range of motion (ROM) exercises to R6's left arm two to three times daily. The order instructed staff to review the restorative nursing program instructions which were posted on the wall in R6's room.R6's care plan, revised 2/26/26, indicated R6 had impaired…

    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
  • Potential for harm · D2026-07-02 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to identify and appropriately monitor target behaviors for 1 of 1 residents (R22) reviewed for mood and behavior. Findings include:R22's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, moderately severe depression, no exhibited behaviors, and received antidepressant medications. R22's diagnosis included major depressive disorder and spinal stenosis (narrowing of spaces in spine putting pressure on spinal cord and nerves causing pain and weakness). R22's care plan dated 6/11/26, indicated R22 had potential for adverse drug reactions (ADRs) related to daily use of psychotropic medications. R22's care plan further identified alteration in mood and behavior related to diagnoses, adjustment to placement, and loss of independence. The care plan instructed staff to monitor target behaviors and ADRs as ordered.R22's PHQ-9 assessment (screening tool used to diagnose and monitor severity of depression with a scale from 0…

    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
  • Potential for harm · Dcited before2026-07-02 · tag F0880 — failed to prevent and control infections — isolated
    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 staff used enhanced barrier precautions (EBP) for 1 of 1 residents (R6) reviewed who required EBP. Findings include:R6's quarterly Minimum Data Set (MDS), dated [DATE], indicated R6 had moderate cognitive impairment. Diagnoses included cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side following a cerebral infarction (blocked blood vessels that deprived part of the brain of oxygen and nutrients). The MDS indicated R6 was dependent on staff for mobility and activities of daily living.R6's provider order, dated 2/10/26, instructed staff to follow enhanced barrier precautions (EBP) related to the gastrostomy tube (G-tube).R6's care plan dated 2/13/26, identified a problem related to the need for EBP due to the G-tube. Interventions included staff following EBP, using appropriate communication regarding EBP, explaining the reasons for EBP, and donning and doffing personal protective equipment…

    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 plan of correction
  • Potential for harm · Dcited before2025-06-12 · 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 ensure care planned interventions to reduce fall risk were implemented for 2 of 2 residents (R4 and R2) reviewed for falls. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE] identified R4 had intact cognition and no behaviors; had limited range of motion on one side of upper and lower extremity. R4 was dependent on a helper to do all the effort to transfer from chair to bed (or bed to chair). Sit to stand was not attempted due to medical condition or safety concerns. R4's care plan dated 6/9/25, identified she was at risk for falls due to impaired mobility and required assist of two staff for transfers using the MAXI lift (full body lift) r/t (related to) diagnoses of vascular dementia, non-traumatic intracerebral hemorrhage (type of stroke), and right sided weakness. R4's Follow Up Question Report dated 4/12/25 through 6/11/25, identified assist of two staff was required to transfer R4 using the MAXI lift with an XL…

    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 · D2025-03-21 · 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 interview and document review, the facility failed to immediately report (within two hours) allegations of sexual abuse to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1 R1's annual Minimum Data Set (MDS) dated [DATE], indicated she was moderately cognitively impaired with diagnoses that included dementia, anxiety, depression, psychotic disorder and post-traumatic stress disorder. R2 R2's quarterly MDS dated [DATE], indicated R2 was cognitively intact with diagnoses that included a fractured rib and weakness. The Nursing Home Incident Report filed on 3/20/25 at 1:32 p.m., identified staff were aware of an incident 3/18/25 at 3:12 p.m., in which R1 reported R1 and R2 had a sexual interaction that started off as consensual and escalated to nonconsensual. R1 alleged R2 pinned or grabbed R1's hands during the incident. On 3/20/25 at 11:22 a.m., during an interview, the administrator stated the report he received from the hospital social worker (SW) on 3/18/25,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · 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 complete a thorough investigation for allegations of sexual abuse for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1 R1's annual Minimum Data Set (MDS) dated [DATE], indicated she was moderately cognitively impaired with diagnoses that included dementia, anxiety, depression, psychotic disorder and post-traumatic stress disorder. R2 R2's quarterly MDS dated [DATE], indicated R2 was cognitively intact with diagnoses that included a fractured rib and weakness. The Nursing Home Incident Report filed on 3/20/25 at 1:32 p.m., identified staff were aware of an incident 3/18/25 at 3:12 p.m., in which R1 reported R1 and R2 had a sexual interaction that started off as consensual and escalated to nonconsensual. R1 alleged R2 pinned or grabbed R1's hands during the incident. The investigative file dated 2/18/25, for the incident between R1 and R2, included an interview by the social worker (SW)-A with R1, a list of R1's diagnoses, a signed…

    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 · D2025-03-21 · 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 and document review, the facility failed to ensure the comprehensive care plan was updated to include interventions to address relationships and behaviors for 1 of 4 residents (R2) reviewed for abuse prevention. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact with diagnoses which included a fractured rib and weakness. R2's care plan printed 3/20/25, indicated R2 was a vulnerable adult however, lacked mention of a relationship between R1 and R2 and lacked instruction to staff to monitor R2's behavior and interactions with female residents. On 3/20/25, at 12:38 p.m., during an interview, social worker (SW)-A stated she informed the director of nursing about R2's behaviors and informed staff to monitor the interactions. The SW-A stated she expected care plans to address monitoring of behaviors and confirmed the behavior was not addressed in R2's care plan. On 3/20/25 at 2:29 p.m., during an interview, nurse practitioner (NP)-A stated staff…

    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 · Fcited before2024-08-07 · tag F0880 — failed to prevent and control infections — widespread
    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 record review the facility failed to ensure transmission-based precautions (TBP) were utilized for 1 of 1 residents (R98) who required contact precautions for clostridium difficile (C. diff, a highly contagious infection). Furthermore, the facility failed to ensure enhanced barrier precautions (EBP) and appropriate hand hygiene was used for 1 of 1 residents (R20) observed during personal cares. Findings include: R98's admission Minimum Data Set (MDS) report dated 8/2/24, indicated intact cognition and a diagnoses of enterocolitis due to c-diff, sepis, and urinary tract infection (UTI). R98's physician's orders lacked indication R98 required contact precautions. R98's care plan dated 8/2/24, lacked indication R98 required contact precautions. R98's progress note dated 8/6/24, indicated R98 was receiving Vancomycin oral solution 250 mg/5 milliliters (ml) and had one large loose stool. During observation on 8/6/24 at 2:31 p.m., R98's room had a sign on the door indicating contact…

    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 · D2024-08-07 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R37). Findings include: R37's Optional State Assessment (OSA) dated 7/10/24, indicated R37 had severe cognitive impairment, did not have behaviors, required extensive assistance with bed mobility, transfers, and toileting. R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 continuously had inattention, disorganized thinking, and an altered level of consciousness that fluctuated. Additionally, R37 rejected care 1 to 3 days, wandered 1 to 3 days, was frequently incontinent of bowel and bladder, had two or more falls with no injury, two or more falls with injury except major injury, was on hospice, and did not use restraints. R37's Medical Diagnosis form indicated the following diagnoses: Alzheimer's disease with late onset, traumatic subdural hemorrhage with loss of consciousness, fracture of unspecified part of neck of right femur, muscle weakness,…

    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 · Dcited before2024-08-07 · 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 record review the facility failed to ensure skin assessments were completed under a removable device for R16 and failed to ensure interventions were implemented for R20 who both were reviewed and at risk for pressure injury. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and had diagnoses of left ankle fracture, lung disease, and schizoaffective disorder. R16's MDS further indicated R16 required assistance with mobility, was at risk for pressure injury and required pressure reliving devices for the chair and bed. R16's orthopedic consultation/clinic referral form dated 7/31/24, indicated R16 had a cam boot (removable splint) for the left lower extremity to wear while weightbearing. R16's provider order dated 6/6/24, indicated R16's left leg splint was to remain clean, dry, and intact until next clinic visit. R16's provider and nursing orders lacked indication they had been updated following R16's orthopedic…

    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
Show the remaining 11 citations
  • Potential for harm · D2024-08-07 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 podiatry services were obtained for 1 of 1 resident (R16) reviewed for foot care. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and had diagnoses of left ankle fracture, lung disease, and schizoaffective disorder. R16's MDS further indicated R16 required substantial assistance for personal cares and was dependent on staff for bathing and dressing the lower body and feet. R16's weekly skin inspection dated 6/14/24, indicated R16 had overgrown toenails however trimming was not necessary. R16's weekly skin inspection dated 6/21/24, indicated R16's toenails were not trimmed and R16 required podiatry to cut toenails due to thickness. R16's weekly skin inspection dated 6/28/24, indicated R16 required a podiatrist for toenail clipping. R16's weekly skin inspection dated 7/19/24, indicated R16 required podiatry to cut toenails due to thickness. R16's care plan dated 6/7/24,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-07 · 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 ensure 1 of 1 resident (R37) with repeated falls had implemented interventions to promote safety and reduce the risk of falls and the facility failed to ensure R37 was free from physical restraints. Findings include: R37's Optional State Assessment (OSA) dated 7/10/24, indicated R37 had severe cognitive impairment, did not have behaviors, required extensive assistance with bed mobility, transfers, and toileting. R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 continuously had inattention, disorganized thinking, and an altered level of consciousness that fluctuated. Additionally, R37 rejected care 1 to 3 days, wandered 1 to 3 days, was frequently incontinent of bowel and bladder, had two or more falls with no injury, two or more falls with injury except major injury, was on hospice, and did not use restraints. R37's Medical Diagnosis form indicated the following diagnoses: Alzheimer's disease with late onset, traumatic…

    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 · D2024-08-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure gradual dose reductions (GDR) were attempted, or an adequate medical justification for the use of psychotropic medications for 2 of 5 residents (R19, R14) reviewed for unnecessary medications. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not have hallucinations, delusions, physical behaviors. R19 had verbal behavioral symptoms 1 to 3 days and did not have other behavioral symptoms and did not reject cares. Further, R19 took antipsychotic and antidepressant medications, a gradual dose reduction had not been attempted and had not been documented by a physician as clinically contraindicated. R19's Medical Diagnosis form indicated the following diagnoses: Parkinson's disease, dementia in other diseases classified elsewhere without behavioral disturbance, history of falling, and insomnia. R19 had the following physician order: 4/28/23, trazodone 150 milligrams (MG) by mouth…

    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 · D2024-08-07 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to provide menu's and alternate food choices to 2 of 2 residents (R14, R98) reviewed for food. R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of congestive heart disease (CHF), type II diabetes. and required setup/clean up assistance with eating. R14's physician's orders dated 6/30/24, indicated a consistent carbohydrate diet, regular texture, regular (thin) consistency, no added salt. Offer assistance cutting foods, related to type II diabetes mellitus. R14's care plan dated 7/24/24, indicated a potential for alteration in nutrition related to diabetes mellitus type II (DMII), obesity, and history of COVID 19, iron deficiency anemia, depression, dementia, dysphagia, and hypertension (HTN) with an intervention to offer substitute for dislikes or when not eating. During interview on 8/5/24 at 1:35 p.m., R14 stated he never knows what he's going to get to eat for each meal and he hadn't received a menu. He…

    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 · D2023-09-07 · 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 document review, the facility failed to ensure dignity was maintained for 1 of 2 residents (R24) reviewed who had not been shaved. Findings include: R24's annual Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and a diagnosis of dementia. R24 required extensive assist from staff with hygiene, and total assistance with transfers. R24 had not rejected care. R24's care plan dated 9/7/23, identified a self-care deficit related to right lower leg amputation and mild cognitive impairment. R24's goal was to be dressed groomed and bathed per preferences and accept assistance. The care plan lacked interventions specific for shaving but identified R24 required assist of one for personal hygiene. R24's progress notes (nurses charting) and point of care (POC) (nursing assistant charting) dated 7/9/23 through 9/7/23, lacked documentation of attempts, or refusals of shaving. R24's POC charting had one instance of refusing care documented on 8/2/23, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure privacy during personal cares for 1 of 2 residents (R27) reviewed for personal cares. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition, required extensive assist for transfers, dressing, toileting, personal hygiene, and was frequently incontinent of bowel and bladder. R27's Medical Diagnosis form undated, indicated R27 had the following diagnosis: major depressive disorder, abnormalities of gait, and muscle weakness. R27's care plan dated 12/22/22, indicated R27 had an alteration in elimination and interventions included: R27 was independent with a rolling walker to and from the bathroom, required assistance with perineal (cleaning private areas) cares in the a.m., bedtime, and as needed; staff were to provide incontinent products and assist to change as needed. R27's care plan also identified R27 required assist of one with personal hygiene, dressing, and bathing. R27's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure grooming was offered and/or provided for 1 of 2 residents (R32) reviewed for shaving. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject cares, and required extensive assistance with dressing and personal hygiene which included shaving. R32's Medical Diagnosis form undated, in the electronic medical record (EMR), indicated R32 had the following diagnosis: cerebral infarction (stroke) due to unspecified occlusion or stenosis of unspecified cerebral artery, adjustment disorder with depressed mood and slurred speech. R32's care plan dated 2/5/21, indicated R32 had an alteration in communication due to a cerebral infarction and interventions included allowing R32 time to communicate his wishes, and anticipate needs so they could be met. R32's care plan additionally indicated R32 had an alteration in mood and behaviors and interventions indicated staff were to monitor 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
  • Potential for harm · Dcited before2023-09-07 · 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 ensure interventions were in place for 1 of 2 residents (R52) at risk for pressure ulcers when an air mattress was not functioning properly. Findings include: R52's 30-day Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact, required one person extensive assistance for most activities of daily living (ADLs) and was at risk for developing pressure ulcers. R52's diagnosis included chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, open wound of left foot, and type 2 diabetes mellitus. R52's Care Area Assessment (CAA) dated 7/14/23, indicated R52 had an alteration in skin integrity related to stage II left heel wound and required a pressure redistribution mattress on his bed. R52's care plan dated 7/17/23, indicated R52 had alteration in skin integrity related to non-healing left heel wound, abrasion on left lateral foot, and skin tear on left lower shin. Interventions included pressure redistribution…

    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 before2023-09-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide a nursing rehabilitation functional maintenance program (FMP) for 1 of 3 residents (R24) who had limited range of motion. Findings include: R24's annual Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition. R24 required extensive assist of staff for bed mobility, locomotion on and off the unit, toileting and hygiene. R24 required total assistance for transfers. R24 could eat independently after set up. R24's diagnosis included dementia and peripheral vascular disease (impaired blood circulation). R24's care plan dated 9/7/23, identified a self-care deficit related to right lower leg amputation and mild cognitive impairment. Interventions included an FMP where R24 performed seated exercises with the nursing assistant (NA) daily. Cues for correct technique and copies of exercises were identified to be in R24's closet. R24's Restorative Nursing Program form dated 7/23/20, identified R24 would perform seated…

    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 · D2023-09-07 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    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 food was palatable for 1 of 2 residents (R207) reviewed. Findings include: R207's Medical Diagnosis form in the electronic medical record (EMR) indicated R207 had the following diagnosis: displaced intertrochanteric fracture of the right femur (broken hip), type two diabetes mellitus, exocrine pancreatic insufficiency (a condition where the small intestine cant digest food), alcohol dependence, Wernicke's encephalopathy (a neurological disorder), major depressive disorder, and general anxiety disorder. R207's Dietary Communication form dated 8/21/23, indicated consistent carbohydrate diet and R207's sodium was not restricted. R207's Clinical Nutrition Evaluation form dated 8/30/23, indicated R207's meal intakes were between 26-50%. R207's physician's orders dated 8/31/23, indicated R207 had an order for a consistent carbohydrate diet, mechanical soft texture, with regular thin consistency, no salads or lettuce, may have popcorn. R207's social services note dated 9/5/23, indicated R207 had intact…

    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
  • No harm found · C2024-08-07 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 complete required nurse staffing information was posted and was timely on a daily basis. This had the potential to affect all 48 residents, staff, and visitors who could wish to review this information. Findings include: On 8/6/24 at 1:57 p.m., form, Estates at [NAME], dated 8/6/24, was located next to the adminstartor's office. The form identified an area to document the census, however, the census number was undocumented. Additionally, the form identified some staff and their titles, but did not identify all staff and their titles and lacked information on the total number and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs). During interview on 8/6/24 at 2:00 p.m., the administrator verified the form, Estates at [NAME], was the staff posting and stated it usually included the census and verified the census was not added on the form and proceeded to write the census…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to MONARCH HEALTHCARE MANAGEMENT — 45 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.2+1.8 vs chain
Health inspection 4 of 52.1+1.9 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 44 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Hillcrest Health Care, LLCMankato, MN 1 of 5Maplewood Rehabilitation CenterMaplewood, MN 1 of 5The Emeralds At Fairbault LLCFaribault, MN 1 of 5The Emeralds At Grand Rapids LLCGrand Rapids, MN 1 of 5The Emeralds At St Paul LLCSaint Paul, MN 1 of 5The Estates At Excelsior LLCExcelsior, MN 1 of 5The Estates At Lynnhurst LLCSaint Paul, MN 1 of 5The Villas At BrookviewGolden Valley, MN 1 of 5The Villas At New BrightonNew Brighton, MN 1 of 5The Villas At Osseo LLCOsseo, MN 1 of 5The Villas At RobbinsdaleRobbinsdale, MN 1 of 5The Villas At The CedarsSaint Louis Park, MN 1 of 5The Waterview Pines LLCVirginia, MN 1 of 5The Waterview Shores LLCTwo Harbors, MN 1 of 5The Waterview Woods LLCEveleth, MN 1 of 5Villas At Bryn Mawr LLCMinneapolis, MN 2 of 5Bayside Manor LLCGaylord, MN 2 of 5Oaklawn Health Care, LLCMankato, MN 2 of 5Parmly On The Lake LLCChisago City, MN 2 of 5The Estates At Chateau LLCMinneapolis, MN 2 of 5The Estates At Fridley LLCFridley, MN 2 of 5The Estates At Roseville LLCRoseville, MN 2 of 5The Estates At Rush City LLCRush City, MN 2 of 5The Estates At Twin Rivers LLCAnoka, MN 2 of 5The Gardens At Foley LLCFoley, MN 2 of 5The Gardens At Winsted LLCWinsted, MN 2 of 5The North Shore Estates LLCDuluth, MN 2 of 5The Villas At St Louis ParkSaint Louis Park, MN 2 of 5The Villas At St PaulSaint Paul, MN 2 of 5The Villas At The ParkSaint Louis Park, MN 3 of 5Bethany On The Lake LLCAlexandria, MN 3 of 5Laurels Peak Health Care, LLCMankato, MN 3 of 5Meeker Manor Rehablitation Center, LLCLitchfield, MN 3 of 5River Valley Health And Rehabilitation Center LLCRedwood Falls, MN 3 of 5The Estates At Bloomington LLCBloomington, MN 3 of 5The Estates At St Louis Park LLCSaint Louis Park, MN 3 of 5The Villas At RichfieldRichfield, MN 3 of 5The Villas At RosevilleRoseville, MN 4 of 5Lakeshore Rehabilitation Center LLCWaseca, MN 4 of 5Mala Strana Health Care, LLCNew Prague, MN

Showing 40 of 44; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
NIJ LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 03/01/2017
SPARTAN HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 03/01/2017
YAZOMA HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 03/01/2017
AREM, JEFFREYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 03/01/2017
STERN, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL20%since 03/01/2017
HALPERT, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR30%since 03/01/2017
JAFFA, NOAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 03/01/2017
LEGUM, JOSHUAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE30%since 03/01/2017
MONARCH HEALTHCARE OPERATING IV LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2017

CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$7.2M
Net patient revenuemost recent cost report
+8.2%
Operating marginrevenue minus expenses
$974K
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 45%Medicare 8%Other / private 47%

This home reported $974K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$356per resident / day
operating cost
$10,823per month
≈ monthly operating cost
$388per 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 245342. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-02, 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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