Oakland Park Communities, Inc.
123 Baken Street, Thief River Falls, MN 56701 · For profit - Individual · 35 certified beds · (218) 681-1675 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- 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 1 actual-harm citation
- inspectors recorded 2 serious findings 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $44,030 in federal fines (most recent 2025-12-30)
- 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)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 34.6% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.1% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.6% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.8% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.8% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.9% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.3% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.0% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.9% | 1.4% | 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.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 35 beds and averages 33.9 residents a day — about 97% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 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 3.19 hrs/resident/day on weekends vs 4.02 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.30 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and document review the facility failed to ensure staff transporting residents in a facility vehicle were trained on safe transport practices and had appropriate driver's license clearance for 3 of 3 (R1, R2, R3) residents reviewed for accidents. This resulted in an immediate jeopardy for R1 when he fell from his wheelchair to the floor of the van during transport after being improperly secured. Findings include: The immediate jeopardy (IJ) began on 7/2/25, at approximately 4:00 p.m., when nursing assistant (NA)-A was directed to transport R1 to the hospital, loaded him in the front passenger's seat of the van, securing only two out of the four required four-point tie downs, and no seat/lap belt. R1's wheelchair fell backwards onto the floor of the van during transport resulting in a skin tear on top of the left hand. Additionally, NA-A driver's license had not been cleared by the facility's insurance prior to this incident. The IJ was identified on 7/17/25, the administrator 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.
- Actual harm · Gcited before2026-02-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement standards of practice to ensure an assessment was completed to safely use of a lift chair for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 had an unwitnessed fall from the lift chair and sustained a trimalleolar fracture (a severe, unstable ankle injury involving fractures of three distinct bones: the lateral malleolus (fibula), medial malleolus (tibia), and posterior malleolus (back of the tibia)) with lateral subluxation of the talus (high-energy trauma (falls) forcing the foot into severe eversion.) R1 was sent to the emergency room (ER) via ambulance and required medical evaluation and treatment. The facility implemented corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's Hospital Discharge summary dated [DATE], identified discharge diagnoses left-side posterior cerebral artery (PCA) stroke territory infarct (affecting the left…
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.
- Actual harm · G2025-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure manufacturer's instructions were followed for the use of a microwave heating of a gel pack, complete a comprehensive assessment of the burn and implement timely interventions to promote the healing of a burn for 1 of 1 resident (R15) reviewed for burns. This resulted in actual harm to R15 who sustained a 3rd degree burn (destroys your first three layers of skin and fatty tissue) from a gel pack. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate assistance to roll her body left and right and currently had no wounds. R15's care plan dated 10/16/24, identified R15 was at risk for pain related to spinal stenosis, osteoporosis, weakness, impaired mobility, shoulder pain, spondylolisthesis osteoarthritis, chronic gout, low back pain, and amputation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 interviews and document review, the facility failed to contact the resident's physician of medication administration omissions for 1 of 3 resident (R1) reviewed who did not receive medications as ordered. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility from an acute hospital 1/15/26. R1's care plan dated 1/16/26, identified she had a recent diagnosis of CVA. Staff were directed to administer medications as ordered and report abnormal labs and/or vital signs to primary care provider. R1's Hospital Discharge summary dated [DATE], identified discharge diagnoses left-side posterior cerebral artery (PCA) stroke territory infarct (affecting the left temporal-occipital lobe as well as thalamus area), hyperlipidemia (high cholesterol levels), hypertension (HTN) (high blood pressure), arteriosclerotic disease, hypokalemia (low potassium), urinary tract infection (UTI), and deep vein thrombosis (DVT) prophylaxis. Hospital course: hypokalemia felt 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.
- Potential for harm · D2026-02-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 interview and document review the facility failed to ensure 1 of 1 resident (R2) reviewed for medication errors was free of significant medication errors when orders for Potassium (electrolyte that carries an electrical charge to balance fluids in the cells, contacts muscles including the heart and transmits nerve signals to the brain) was not transcribed into the electronic medical record according to physician's orders and resulted in at least six missed doses of Potassium 10 milliequivalent (mEq).Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility from an acute hospital 1/15/26. R1 had slurred or mumbled words, responded adequately to simple, direct communication only, impaired vision, disorganized thinking, and severely impaired cognition. R1's medical included history of cerebral vascular accident (CVA) (stroke) and urinary tract infection (UTI).R1's care plan dated 1/16/26, identified she was at nutritional risk due to aphasia (a sudden…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-31 · tag F0582 — isolatedGive 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 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN CMS10055) and the Notice of Medicare Non-Coverage (NOMNC CMS-10123) was provided to 1 of 3 residents (R17) reviewed for beneficiary notification. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was cognitively intact. R17 was admitted on [DATE], and there was functional range of motion in both upper and lower extremities and was not receiving therapy services. R17's medical record identified R17 started Medicare Part A services on 5/22/25, and last covered day of Medicare Part A services was 7/1/25. R17's medical record that a SNFABN or NOMNC was issued to the resident. The medical record lacked evidence R17 was made aware of the cost of continuing services or on how to appeal the ending of services. During an interview on 12/30/25 at 4:26 p.m., the administrator stated the notices were to be completed by the social services designee or the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-31 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 written bed hold notice to resident/resident's representative at the time of transfer to hospital for 1 of 1 resident (R12) reviewed for hospitalizations.Findings include: R12's discharge Minimum Data Set (MDS) dated [DATE], identified R12 had an unplanned discharge with return anticipated. Diagnoses included chronic obstructive pulmonary disease (COPD), diastolic heart failure (CHF), atrial fibrillation (irregular heartbeat) and myocardial infarction (heart attack). R12's progress note dated 12/9/25, identified R12 was admitted to the hospital for fever and shortness of breath with concern of a CHF exacerbation. R12's medical record lacked evidence a written notice for bed hold was provided, that specified the duration of the bed hold, the reserve bed payment policy and the nursing facility's policies regarding bed hold periods. During interview on 12/30/25, at 2:20 p.m. the unit manager (UM)-B stated when the facility received a call from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 document review, the facility failed to revise the resident's care plan to reflect accurate behaviors and interventions to mitigate behaviors for 1 of 1 resident (R18) reviewed for behavioral health.Findings include:R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had moderately impaired cognition. R18 required maximum assistance with dressing and grooming, dependent with toileting and transfers and was unable to ambulate. R18 exhibited physical behavioral symptoms toward others such as hit, kick, push or grab one to three times per week and other behavioral symptoms not directed toward others such as rummaging, and/or verbal symptoms one to three days per week. R18 received antipsychotic and antidepressant medications on a routine basis. Diagnoses included Alzheimer's disease, dementia, restlessness and agitation, diabetes and depression. R18's nursing progress notes identified the following:11/19/25, Seen by physician on rounds with orders 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.
- Potential for harm · D2025-12-31 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 facility antibiotic stewardship program was followed for antibiotic use for 1 of 1 resident (R23) reviewed for antibiotic use. Findings include:R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had significant cognitive impairment. R23 required total assistance with all activities of daily living (ADLs) and was incontinent of bowel and bladder. Diagnoses included Alzheimer's disease, anxiety, and urinary tract infection (UTI).R23's progress notes identified R23 was seen in the emergency room on [DATE] for possible seizure activity. R23 was diagnosed with a UTI and Keflex (an antibiotic) was ordered 500 milligrams (MG) two times per day for seven days. R23's medical record identified the following:12/15/25, a urine sample was obtained which identified many bacteria and was set up for culture. 12/16/25, a physician progress note identified R23 was seen on rounds. The physician noted R23 had been started on Keflex to treat a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-31 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits for vaccinations being offered along with offering the most recent pneumococcal vaccine for 1 of 5 residents (R21) reviewed for immunizations.Findings include:R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 was admitted to the facility on [DATE], was [AGE] years old, had moderate cognitive impairment, and had a diagnosis of heart failure. R21's immunization record dated 12/31/25, identified R1 had a historical record R1 had received the pneumovax vaccination on 10/23/02. However, R21's medical record failed to identify R21 or R21's representative was provided the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal.During an interview on 12/31/25 at 10:38 a.m., the interim director of nursing (IDON) stated a resident's immunization stated was reviewed upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure licensed nursing staff hours were submitted accurately on the payroll-based journal. This had the potential to affect all 32 residents residing in the facility. Findings include: The PBJ (payroll-based journal) Staffing Report CASPER Report 1705D FY [fiscal year] Quarter 4 2024 (July 1 - September 30) identified the facility had excessively low weekend staffing and failed to have licensed nursing coverage 24 hours/day on the following days: 7/23/24, 7/24/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24. The facility payroll and working scheduled were reviewed for 7/1/24 through 9/30/24 and there was a licensed nursing staff 24 hours/day consecutively on all 36 days identified on the PBJ report. During an interview on 1/29/25 at 8:49 a.m., registered nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and document review, the facility failed to develop, monitor, and evaluate their identified performance measures. This had the potential to affect all 46 residents residing in the facility. Findings include: The Facility assessment dated 1/2025, identified the facility was a Medicare and Medicaid certified skilled nursing facility. The facility was licensed for 35 beds with an average daily census in the past year of around 34. The facility provided skilled nursing, unskilled nursing, short- and long-term care. Additional services offered are care for those with dementia or other cognitive deficits, end-of-life care, behavioral health, spiritual care, nutritional services, housekeeping, laundry, wound care, ostomy care, dialysis coordination, care of chronic and acute illnesses, oxygen therapy, physical/occupational/speech therapies, restorative and functional maintenance programs, care coordination with physicians, clinics and specialists. Facility Assessment and QAPI Information from the Facility Assessment was used to inform the Quality Assurance Performance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure the quality assurance (QA) committee held meetings with the required members on a, at minimum, quarterly basis. This had potential to affect all 32 residents residing in the facility at the time of the survey. Findings include: The Quality and Safety Meeting minutes dated 7/18/24, failed to identify the medical director was in attendance or had been provided the information for review and provide opportunity for feedback. The Quality and Safety Meeting dated 10/16/24, identified the director or nursing, consultant pharmacist and medical director were not in attendance or had been provided the information for review provide opportunity for feedback. During an interview on 1/30/25 at 2:13 p.m., with the director of nursing (DON) and registered nurse (RN)-D, RN-D stated the administrator was unavailable for interview. RN-D stated the information in the meeting minutes identified the required members did not attend; however, believed they were available by phone at any time needed. The facility policy Quality…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Fcited before2025-01-30 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R14, R15) with wound care and failed to ensure personal protective equipment was used during the sorting of soiled laundry. Findings include: EBP: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had a severe cognitive impairment and diagnoses included dementia, anorexia, and chronic kidney disease. R14 was at risk for pressure ulcers but had no current pressure ulcers. R14's care plan revised 1/13/25, failed to identify R14's right great toe wound and/or the need for enhanced barrier precautions (EBP) to prevent infection. During an observation on 1/29/25 at 1:57 p.m., NA-A assisted with personal hygiene and pivot transfer from R14's bed to wheelchair. NA-A did wear gloves but failed to wear a gown during high contact activities. There was no signage, personal protective equipment (PPE) and/or cart in R14's room. During an observation 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.
- Potential for harm · Dcited before2025-01-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 inform the physician of a burn for 1 of 1 resident (R15) reviewed for burns; and failed to inform the physician of a resident fall with significant bruising 1 of 1 resident (R29) reviewed for falls. Findings include: R15: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate asssistance to roll her body left and right and was at risk for pressure ulcers. R15's care plan dated 10/16/24, identified R15 was at risk for pain related to spinal stenosis, osteoporosis, weakness, impaired mobility, shoulder pain, spondylolisthesis osteoarthritis, chronic gout, low back pain, and amputation of the second toe of the right foot. Non-pharmacological pain interventions may include: rest, reposition, distraction, elevation and ice/warm pack. The care plan directed to update R15's physician with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 report a burn that resulted from the inappropriate use of a hot pack to the state agency (SA) for 1 of 1 resident (R15) reviewed for wound care. Findings include: The Rester's Choice Gel Pack undated manufacturer's instructions directed the following: Clean microwave before use. Gel pack must be at room temperature before microwave use. Distribute gel evenly in pack and place in microwave. Before removing gel pack from microwave, check for leakage. If leakage occurred, wait for the gel pack to cool down and discard. Check for desired temperature (temperature will continue to rise slightly). If pack is too hot, let it cool until temperature is acceptable. If additional heat is desired, return to microwave and heat in 5 second increments. DO NOT overheat. Excessive heating might cause pack to rupture and leak. Place it in the provided pouch. Apply to affected area and use the strap as necessary to hold in place. Store at room temperature for future hot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 investigate a burn that resulted from the inappropriate use of a hot pack for 1 of 1 resident (R15) who was reviewed for wound care. Findings include: Rester's Choice Gel Pack manufacturer's instructions directed the following: Clean microwave before use. Gel pack must be at room temperature before microwave use. Distribute gel evenly in pack and place in microwave. Before removing gel pack from microwave, check for leakage. If leakage occurred, wait for the gel pack to cool down and discard. Check for desired temperature (temperature will continue to rise slightly). If pack is too hot, let it cool until temperature is acceptable. If additional heat is desired, return to microwave and heat in 5 second increments. DO NOT overheat. Excessive heating might cause pack to rupture and leak. Place it in the provided pouch. Apply to affected area and use the strap as necessary to hold in place. Store at room temperature for future hot therapy use. Do not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R15) reviewed for MDS accuracy. Findings include: R15's significant change Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included Type 2 Diabetes. R15 received an insulin injection weekly. R15's Order Summary Report dated 6/20/23, identified R15 received Trulicity (an antihyperglycemic - glucagon-like peptide-1 (GLP-1) receptor agonists) (used with a proper diet and exercise program to control high blood sugar in people with type 2 diabetes) subcutaneous solution pen-injector 3 milligram (mg)/0.5 milliliter (ml). Inject 3 mg subcutaneously in the morning every Thursday related to type 2 diabetes. During an interview with the registered nurse (RN)-D on 1/29/25 at 11:32 a.m., RN-D stated she was assisting with completing resident MDS while the facility's MDS nurse was out of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed comprehensively assess a pressure ulcer and implement interventions to promote healing for 1 of 2 residents (R14) reviewed for wound care. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had a severe cognitive impairment and diagnoses that included dementia, anorexia, and chronic kidney disease. R14 was at risk for pressure ulcers but had no current pressure ulcers. R14's Braden Scale for Predicting Pressure Sore Risk dated 1/7/25, identified R14 was at risk for pressure ulcers. R14's care plan revised 1/13/25, identified R14 was a risk for skin breakdown related to impaired mobility, incontinence, low adipose tissue and impaired cognition. Staff were directed to perform the following: assist R14 to turn/reposition at least every 2-3 hours when up in her wheelchair and all-night rounds, barrier cream will be applied as needed, Braden scale to be completed per facility policy, bruises would be observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure as needed pain medications were available to treat acute break through pain for 1 of 2 residents (R27); and failed to respond to request for pain medications for 1 of 2 residents ( R29) reviewed for pain management. Findings include: R27: R27's quarterly Minimum Data Set (MDS) dated [DATE], identified R27 had severe cognitive impairment and had impaired range of motion in both upper and lower extremities. R27 received both scheduled and as needed pain medications. There were nonverbal sounds and facial expressions of pain observed three to four days per week. R27's Quarterly Pain assessment dated [DATE], identified R27 received scheduled pain medication and PRN pain medication, and having received no non-medication interventions for pain. R27 was unable to answer pain interview questions so a staff assessment for pain was completed. Pain was observed with non-verbal sounds such as crying, whining, gasping or moaning and facial expressions of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a medication allergy was clarified prior to administering medication and failed to ensure as needed (PRN) medication was administered under the recommended daily dose for 1 of 1 resident (R27) reviewed for pain. Findings include: R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had severely impaired cognition. R27 received both scheduled and as needed pain medications. R27 had daily non verbal sounds and facial expressions of pain. R27's Physician Order Summary report dated 1/29/25, identified R27 was ordered acetaminophen 1000 milligrams (mg) three times a day with start date of 1/25/24, as well as acetaminophen 650 mg every four hours as needed with start date 10/31/21. Oxycodone 5 mg every 12 hours as needed was also ordered for severe pain with start date 2/9/24. R27's November Medication Administration Record (MAR) 2024, identified acetaminophen 1000 mg was administered three time on 11/29/24, along with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the consulting pharmacist failed to identify and report irregularities related to resident allergies for a prescribed medication for 1 of 1 resident (R27) reviewed for pain. Findings include: R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had severely impaired cognition. R27 received both scheduled and as needed pain medications. R27 had daily nonverbal sounds and facial expressions of pain. R27's Physician Order Summary report dated 1/29/25, identified an order for oxycodone 5 mg every 12 hours as needed was also ordered for severe pain with start date 2/9/24. R27's Medication Administration Record (MAR) for September 2024 through December 2024 identified allergies on each MAR and included an allergy to oxycodone. The MAR's identified the following: - September 2024, PRN oxycodone was administered to R27 five times during the month of September, despite oxycodone was listed as an allergy in R27's medical record. - October 2024, PRN oxycodone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-21 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 document review, the facility failed to ensure soiled and potentially contaminated linen and resident laundry was sorted in a manner to reduce the risk of cross contamination and subsequent infection spread. These findings had the potential to affect all 34 residents residing in the facility. Findings include: On 3/20/24 at 8:34 a.m., a laundry tour was completed with laundry aide (LA)-A present. LA-A stated the nursing assistants (NA)'s place residents personal clothing into clear or red plastic bags, tie the bags and then place in large yellow bins. Facility laundry was placed in another large yellow bin. The red plastic bags were used when the clothing was soiled with blood, emesis or bowel movement (BM). The laundry staff then brought the yellow bins down to the dirty laundry for sorting and washing. LA-A stated she always wore gloves when sorting and washing the laundry; however, had not been instructed to wear a gown to protect her clothing to complete the process. There were no gowns observed in the area for staff to use to sort the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-21 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 of interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PCV20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R3, R6, R7, R15) reviewed for immunizations. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was [AGE] years old and diagnoses of atrial fibrillation (a-fib). R3's undated immunization record identified R3 received the pneumococcal conjugate vaccine 13 variant (PCV13) on 4/25/16, and the pneumococcal polysaccharide vaccine (PPSV23) on 2/23/10. R3's medical record lacked documentation the PCV20 and PPSV23 were offered and/or education was provided in conjunction with the provider and R3/R3's representative. R6's admission record identified R6 was [AGE] years old. Diagnoses included chronic kidney disease and heart failure. R6's undated immunization record identified R6 received the PCV13 vaccine on 11/23/15 and the PPSV23 on 11/28/11. R6's medical record lacked documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-21 · tag F0920 — patternProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide adequate dining room space to provide adequate space to move residents for 14 of 32 residents (R2, R4, R5, R8, R12, R17, R19, R22, R23, R26, R27, R30, R31, R34) who dined in the facility dining room for meals. Findings include: During observation of facility dining on 3/19/24, from 11:50 a.m. to 12:30 p.m. the dining room had seven dining room tables set up with four to five residents seated at each table in wheelchairs and dining room chairs. Residents were bumping into one another in attempt to leave the dining room after completing their meal. All seven tables with residents in wheelchairs had 8 inches (in) or less between handles of wheelchairs. Staff were moving walkers and wheelchairs to serve residents food and beverages's or to reach across entire table to hand items to resident due to inability to navigate between the tables. - An unidentified nurse aide (NA) wheeled R26 back, away from the dining room table approximately 2 feet (ft), interrupting her lunch meal, in order to wheel another resident to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 review for and/or complete a significant change in status assessment (SCSA) when two or more areas of change in resident status were identified for 1 of 1 resident (R17) reviewed for nutrition. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had no cognitive impairment and was independent with activities of daily living (ADL)'s. R17's most recent weight was 137 pounds (lbs.) and had a weight loss of greater than 5% over the last month or 10% or more in the past 6 months that was not on a physician-prescribed weight-loss regimen. R17's medical record identified the following weights: - 12/1/23, weight: 148 lbs. - 1/18/24, weight: 132 lbs. - 2/15/24, weight: 127 lbs. - 3/15/24, weight: 123 lbs. The medical record identified R17 had a 4 lb or 3.15 % weight loss in one month, and a 25 lb or 16.89 % weight loss in 5 months. The medical record failed to identify a SCSA for significant weight loss. R17's progress notes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to obtain and use the recommented lift sling as directed and failed to assess for the cause of a failed lift sling for 1 of 4 residents (R30) reviewed for safe mechanical lift transfers. Findings include: R30's significant change Minimum Data Set (MDS) dated [DATE], identified R30 had moderate cognitive impairment and was dependant on staff for transfers and R30 did not ambulate. Diagnoses included brain damage, dementia, morbid obesity and a history of falls. R30's progress physical therapy note dated 7/3/23, directed staff to use a full mechanical lift for all transfers, use an extra large toileting sling and to use a bariatric commode with toileting. The facility purchase invoice dated 7/7/23, identified a size large toileting lift sling with belt was purchased for R30. Directions for the sling identified toileting lift slings must only be used when transferring a resident from a seated postion. The lift sling fit most patient lift brands.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 1 resident (R17) reviewed for weight loss. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had no cognitive impairment, and required setup and clean up assistance with eating. R17 had a weight loss of greater than 5% over the last month or 10% or more in the past 6 months, that was not on a physician-prescribed weight-loss regimen. R17's quarterly nutrition assessment progress note dated 1/14/24, identified R17's current weight on 1/3/24 was 136 lbs., and on 12/1/23, resident weighted 148 lbs. Weight loss was undesirable and significant weight loss of 11 lbs. or 7.7%. R17's intake had recently decline, had been refusing many meals, and eating most meals in her room. Because of poor oral intake with weight loss, staff will offer nutritional supplements as well as will weigh R17 2 times per month to monitor. Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-03-21 · tag F0732 — widespreadPost nurse staffing information every day.
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 the required daily nurse staffing information was updated daily with schedule changes. This had the potential to affect all 34 residents, as well as staff and visitors who may have wished to view the information. Findings include: During observation on 3/18/24 at 7:20 p.m., the facility daily staff posting was posted on the wall near the main nurses station. The posting included the date, direct care nursing staff shifts, numbers, census and total hours worked. The facilities daily staff postings and actual working schedules were reviewed from 3/18/24 through 3/21/24. The hours and shift from the schedule, did not match the nurse staff posting hours and shifts per nursing discipline when the schedule was changed. Review of the daily nursing hours posting dated 3/18/24, identified no licensed staff for the 10:00 p.m. through 6:30 a.m. (night) shift. On 3/18/24 at 7:43 p.m., the assistant director of nursing (ADON) stated she had worked the afternoon and would be working until later in the evening. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$44,030 in federal fines across 2 penalties.
- $26,685 — penalty dated 2025-12-30
- $17,345 — penalty dated 2025-07-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BIRCHEM, JAMES | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 03/01/2017 |
| BIRCHEM, KATHLEEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 03/01/2007 |
| CASTILLON, ADINA | Individual | W-2 MANAGING EMPLOYEE | — | since 01/30/2023 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $182K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245592. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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.