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Prairie View Senior Living

250 Fifth Street East, Tracy, MN 56175 · For profit - Individual · 45 certified beds · (507) 629-3331 Medicare & Medicaid certified

Call the home — (507) 629-3331 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 2024
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • 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 (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
551 Highway 14 E · (507) 734-3456 · Call to confirm hours
Pharmacy
131 3rd St · (507) 629-3801 · Call to confirm hours
Grocery
701 Craig Ave · (507) 629-6088 · Call to confirm hours
Park
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 3 of 5
Long-stay residentspeople who live here 3 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 held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.5%18.2%15.4%worse
Long-stay residents who lose too much weight1.5%4.1%5.4%better
Long-stay residents with a catheter left in their bladder1.4%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.7%2.6%2.0%worse
Long-stay residents with depressive symptoms0.0%4.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%4.0%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened21.2%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.0%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers1.6%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control33.7%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.9%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%82.7%79.4%better
Short-stay residents rehospitalized after admission39.4%23.5%22.6%worse
Short-stay residents with an outpatient ER visit15.7%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.681.611.67typical
Long-stay outpatient ER visits per 1,000 resident days4.291.901.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.0% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.0%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
55.0%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 55.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.0%CMS range 39.9–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.3–14.610.7%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 discharge55.0%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 discharge50.0%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 discharge40.0%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 identified95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization6.3%CMS range 3.0–15.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

0.56
RN hours/ resident / day
0.41
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.25
RN hoursweekends
50.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 42.0 residents a day — about 93% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.81 hrs/resident/day on weekends vs 3.34 on weekdays — 16% thinner on weekends. RN hours go from 0.69 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

4
deficiencies at the latest standard inspection (2026-05-20)
8
at the previous standard inspection (2025-04-16)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2026-05-20 · 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

    Based on observation, interview, and document review, the facility failed to facility failed to maintain surveillance of staff illness for preventing, monitoring and investigating illnesses to control infections for 1 of 1 infection control program. This had the potential to affect all 41 residents. The facility also failed to appropriately clean, rinse, and air-dry nebulizer apparatuses (mask, cup) after medication administration for 3 of 3 residents (R9, R14 and R21) and ensure 3 of 3 observed stand lifts, located in the 200 and 300 wing were appropriately cleaned between resident use. Findings include: SURVIELLANCE Review of the 2024-2025 Norovirus Information for Long-term Care Facilities, located at, https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf, identified Norovirus is transmitted through a fecal (stool)-oral route with symptoms of diarrhea, vomiting, nausea, abdominal pain, low grade fever, headache, and or body aches. Individuals generally become ill 12-48 hours after exposure (swallowing Norovirus). Infected individuals shed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 1 of 1 resident's (R36) room was maintained in a homelike manner and ensure preventative maintenance was provided to repair numerous chips and scratches in the pain on 2 of 4 walls.Findings include: R36's comprehensive Minimum Data Set (MDS), accepted on 9/5/25, identified R36 was re-admitted to the facility in November 2023, with diagnoses of heart failure, high blood pressure, and arthritis. R36 had intact cognition and had no behaviors noted. Observation on 5/18/25 at 10:25 a.m., of R36 ion her room identified R36 was seated in her chair. R36 was alert and oriented and stated she had been at the facility for a while. R36 had numerous chips on the walls directly behind her chair and on the right side of the bed, approximately 10 to 12 inches on the wall, above the mattress. When asked about the chips and scuffs in the paint, R36 stated they had always been there since she moved in. Interview on 5/20/26 at 1:00 p.m., with the administrator identified the maintenance director (M-D) was out at 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to have documented communication between the facility and hospice per their written agreement and ensure hospice notes were included in the medical record for 1 of 1 sampled hospice resident (R5). Findings include: R5's comprehensive Minimum Data Set (MDS) assessment, accepted on 9/24/25 identified R5 was re-admitted to the facility in September 2024, with diagnoses of dementia, anxiety disorder and had moderately impaired cognition. R5's current, undated care plan identified R5 has a terminal prognosis requiring hospice involvement/palliative care related to his end stage disease process. Comfort, dignity and autonomy was to be maintained at the highest level and was to demonstrate peacefulness and calmness through body language and/or verbalization. Review of R5's electronic medical record (EMR) hospice notes identified R5's R5 had hospice notes, schedules, and care plans captured in the EMR for the following months:February 2025, 9 times.March 2025, 6 times.April 2025, 5 times.May 2025, 1 time.June 2025 through August…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0949 — failed to train staff on dementia and abuse — isolated
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    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 2 of 8 sampled staff (director of nursing (DON) and nursing assistant (NA)-C) had initial or annual Alzheimer's and dementia training. Findings include: Review of the facility Employee Roster, Job and hire date document identified nursing assistant (NA)-C's had a hire date of 2/23/26. Review of her Alzheimer's Disease or Related Disorder Training identified she had not completed training for an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. Review of the facility Employee Roster, Job and hire date document identified director of nursing (DON) had a hire date of 5/28/24. Review of her Alzheimer's Disease or Related Disorder Training identified she had not completed training for an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. Interview on 5/19/26 at 4:25 p.m., with 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 record review the facility failed to notify physician of skin alteration for 1 of 3 (R1) residents reviewed for change of condition. Findings include R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition. R1 had infection to the foot and was receiving application of nonsurgical dressing with ointment/medication to her feet.R1's progress note dated 6/4/25 at 1:30 p.m., indicated R1 was admitted via electric scooter from local hospital with many bruises on arms and an open area left great toe. R1's progress notes dated 6/5/25 at 4:08 a.m., indicated admission skin assessment completed and there were multiple bruises noted on bilateral arms and legs and dressing remained intact to left great toe.R1's record reviewed between 6/5/25 through 6/11/25 revealed although the progress notes identified R1 had developed skin changes to her right foot that included discoloration, a large bump, and a large fluid filled blister, it was not evident the physician was notified…

    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 · F2025-04-16 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 implement thier facility assessment to ensure 1 of 1 licensed practical nurse (LPN)-A and potentially 8 other licensed nurses (registered nurses (RN's) and LPN's) who administered insulin had yearly competencies for safe administration of insulin, and identifcation of complications of low or high blood sugar levels and any actions needed. This had the potential to affect all residents who were diabetic. Finding include: R15's 1/21/25, Significant Change Minimum Data Set (MDS) assessment identified R15 cognition was intact, he had no pain, no behaviors, was on a therapeutic diet, received insulin, anticoagulant, diuretic, hypoglycemic medication daily and was on isolation. R15's diagnosis list identified he had diabetes mellitus type 2, long term use of insulin, heart failure, chronic kidney disease, edema, atrial fibrillation, and hypertension. R15's January 2025, Medication Administration Record identified R15 received insulin Glargine Solution 48…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-16 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 43 residents. Review of the facilities QAPI minutes from June of 2024 through March of 2025 identified the following: 1. June 2024 minutes identified the facility chose a PIP of pain. The minutes did not include any data collection, analysis, evaluation of the identified concern, or an action plan. 2. July, August, September, October, November, December of 2024 and January, February, March of 2025 QAPI minutes identified the facility chose a PIP of pain but lacked any data collection, analysis or evaluation of the identified concern or an action plan. Interview on 4/15/25 at 4:30 p.m., with the administrator identified the QAPI committee had chosen pain from the facilities CMS Quality measures as their PIP project back in June. He reported they had 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to notify the Office of the Ombudsman of transfers and discharge for 2 of 5 residents (R29 and R39) reviewed for hospitalizations and/or discharges. Findings include: R29's 3/16/25, discharge return anticipated Minimum Data Set (MDS) assessment identified an unplanned discharge to general hospital. 3/19/25 an entry tracking record was completed. R39's 2/3/25, discharge return not anticipated MDS identified he returned to home/community. Review of the February and March 2025 Monthly Notice to Office of Ombudsman for Long-Term Care of Emergency Acute Care Transfer and Discharges form identified that neither R29 nor R39 were on the list of resident who had been discharged . Interview on 4/16/25 at 9:20 a.m., with social service designee (SSD) identified she notified the ombudsman monthly of any hospital discharges. She did not notify the ombudsman of any other types of discharges. She reported that the nurse took care of ombudsman notification if a resident discharged to home or anther facility. She confirmed that R29'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 · D2025-04-16 · tag F0641 — isolated
    Ensure 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 resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 12 sampled residents (R13 and R14). Findings include: R13 was admitted [DATE]. R13's undated, current diagnosis list identified R13 received a diagnosis of bipolar disorder 11/05/24. R13's 3/03/25, Level II PASARR had indicated R13 had meet criteria for severe mental illness. R13's 3/28/25, Significant change Minimum Data Set (MDS) identified R13 was moderately, cognitively impaired and had a diagnoses of anxiety, bipolar disease and dementia. R13 had little interest or pleasure in doing things, never to 1 day and felt down, depressed or hopeless 2 to 6 days. R13 was dependent with ADLS and required substantial maximal assist with transfers. R13 had taken antipsychotics, antianxiety and antidepressant on a routine basis. Section A 1500 PASARR: resident been evaluated by [NAME] II PASARR and determined to have a serious mental illness and/or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 1 of 1 resident (R15) rapid acting insulin injection was administered according to the manufactures instructions. Finding include: R15's 1/21/25, Significant Change Minimum Data Set (MDS) assessment identified R15 cognition was intact, he had no pain, no behaviors, was on a therapeutic diet, received insulin, anticoagulant, diuretic, hypoglycemic medication daily and was on isolation. R15's diagnosis list identified he had diabetes mellitus type 2, long term use of insulin, heart failure, chronic kidney disease, edema, atrial fibrillation, and hypertension. R15's January 2025, Medication Administration Record identified R15 received insulin Glargine Solution 48 units every morning and evening and Fiasp insulin aspart injection solution 32 units three times a day at 8:00 a.m., noon, and 5:00 p.m R15's medication administration audit report identified documentation on 1/26/25 at: 1) 9:17 a.m., Fiasp insulin 32 units had been administered. 2) 9:18…

    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
Show the remaining 13 citations
  • Potential for harm · D2025-04-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure only authorized personnel entered 1 of 1 medication storage room. Findings include: Observation and interview on 4/16/25 at 8:24 a.m. of licensed practical nurse (LPN)-A wheeled R8 into the medication storage room adjacent to the dining room. LPN-A donned gloves and primed Humulin Kwik pen with 2 units. LPN-A identified R8's blood sugar was 171 and then dialed up 20 units of insulin for administration. LPN-A administered the insulin in R8's left abdomen and discarded the insulin needle in the sharp's container and removed her gloves. LPN-A then wheeled R8 back out to the dining room table. LPN-A reported that typically she did not give insulin in the medication room however R8 had gotten out the dining room before she caught her to give her insulin. She also revealed that there were typically 2 licensed nurses on duty during the daytime hours and today she was the only licensed nurse on duty with a trained medication aide (TMA) so she had to give all the insulins in the facility so that was why she gave the insulin in…

    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 · D2025-04-16 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure 1 of 1 nursing assistant (NA-A) entering the food preparation area in the kitchen wore a hair net. Findings include: Observation and interview on 4/14/25 at 12:25 p.m., of NA-A standing in the kitchen food preparation area where the cook was dishing up the meal onto plates. NA-A was standing within 2 feet of the cook dishing up the food onto the plate with no hair net on. NA-A obtained a meal tray and exited the kitchen. When asked about hair nets when in the kitchen NA-A stated, I do not think the nurse aides have to wear one. She denied that she typically goes into the kitchen to retrieve a meal, then reported, the resident was out in the dining room, but then changed their mind and wanted to eat in their room. Interview on 4/14/25 at 12:32 p.m., with dietary manager identified staff were able to enter the kitchen as far as the hand washing sink which was just inside the kitchen door. Any distance after that they need to have the hair net on. She confirmed there should be no staff without hair nets in the kitchen…

    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 · Dcited before2025-04-16 · 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

    Based on observation, interview, and document review, the facility failed to ensure 1 of 1 medication room was not used for resident insulin administration and/or blood glucose checks, in order to prevent potential cross-contamination. Observation and interview on 4/16/25 at 8:24 a.m. of licensed practical nurse (LPN)-A wheeled R8 into the medication storage room adjacent to the dining room. LPN-A donned gloves and primed Humulin Kwik pen with 2 units. LPN-A identified R8's blood sugar was 171 and then dialed up 20 units of insulin for administration. LPN-A administered the insulin in R8's left abdomen and discarded the insulin needle in the sharp's container and removed her gloves. LPN-A then wheeled R8 back out to the dining room table. LPN-A reported that typically she did not give insulin in the medication room however R8 had gotten out the dining room before she caught her to give her insulin. She also revealed that there were typically 2 licensed nurses on duty during the daytime hours and today she was the only licensed nurse on duty with a trained medication aide (TMA) so…

    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 · D2024-09-18 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 3 of 12 days reviewed. This had the potential to affect all 44 residents. Findings include: Review of random nursing staff schedules and time punches for 7/24/24, /25/24, 8/11/24, 8/12/24, 8/16/24, 8/17/24, 8/18/24, 9/7/24, 9/8/24, 9/14/24, 9/15/24, and 9/16/24 identified: 1) On 8/16/24, registered nurse (RN)-A had punched in for work for 3.2 hours. The facility lacked evidence that any other RN had worked that day. 2) On 8/17/24, RN-B had punched in for work for 3.9 hours. The facility lacked evidence that any other RN had worked that day. 3) On 8/18/24, the facility lacked evidence that an RN had worked that day. Interview on 9/18/24 at 12:38 p.m., with business office manager identified she review RN coverage each payroll. She confirmed that RN-A had only worked 3.2 hours on 8/16/24 and revealed that no other RN had worked that she could tell. A follow up interview at 1:16 p.m., with business office manager revealed that RN-C had…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · 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 follow manufacturer's safety instructions for safe transfers for 1 of 2 residents (R4) who was not transferred with the appropriate mechanical lift sling. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated severe cognitive impairment with the diagnoses of aphasia, dementia, anxiety, and depression. R4 had physical and verbal behaviors toward others, and rejection of cares one to three days during the look back period. R4 had impairment to one side of upper extremity and used a wheelchair. R4 was dependent for all his activities of daily living (ADLs) except for dressing of upper body, which required partial assist. R4 did not walk. R4's ADL care related to transfers dated 12/7/23, directed staff to use two staff assistance to transfer with mechanical lift. R4's care plan did not identify the size and type of sling R4 required. During an observation on 7/30/24 at 12:17 p.m., R4 had returned from hospital and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-31 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop 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 ensure 3 of 5 residents (R6, R10, and R11) were appropriately vaccinated against pneumonia and offered updated vaccinations and/or additional vaccinations when identified or upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offered or provided any initial or updated vaccines to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · 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

    Based on interview and document review, the facility failed to ensure an allegation of misappropriation of a resident's money was reported to the State Agency (SA) in a timely manner for 1 of 2 residents (R11) reviewed. Findings include: R11's 11/14/23, quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and he required some assistance from staff with toileting, dressing, and personal hygiene. R11 had diagnosis of dementia, and non-compliance and used a wheelchair or walker for mobility. Interview on 1/29/23 at 10:21 a.m., R11 identified he was missing $330.00. He identified that he had reported the missing money and stated, they said they would investigate but it never happened He was not certain of the dates that the money had went missing, but it had been during the last few months. Interview on 1/30/24 at 1:36 p.m., with the administrator identified when money or something of value is reported missing and they are unable to locate the missing item, they file a report to the SA and complete an internal investigation. The administrator identified he did…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · 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 R17's admission Minimum Data Set (MDS) dated [DATE], identified her cognition was moderately impaired and had a diagnosis of dementia, anxiety, and depression. Review of 12/19/23, report to the State Agency (SA) identified R17 stated she was missing $100.00 that her son left her in her top drawer. The facility spoke to family members (FM)-E and FM-D, who identified FM-E had brought $100.00 in twenty-dollar bills to the facility. When he had returned a week later, the money was gone. FM-E reported he assumed staff had placed it in the facility safe and did not report it missing. The administrator searched the facility safe and the money was not there. With permission from R17 the administrator searched her room. While searching the room, R17 reported she thought her husband had taken the money home with him. The facility was unable to reach the husband for interview. The facility had interviewed 12 staff who denied knowing the money was in R17's room or taking any money from R17's room and had notified local law…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0868 — isolated
    Have 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 document review and interview, the facility failed to ensure 1 of 1 required member (infection preventionist) and/or their designee attended the quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the quarterly QAPI meeting attendance forms for February 2023, May 2023, August 2023, and November 2023, identified the facility infection preventionist was not present at the meetings however, her name and title of ADON/Infection preventionist was listed as a member of the committee. Interview on 1/31/24 at 1:18 p.m., with registered nurse (RN)-C who was also the infection preventionist identified the reason she did not attend the QAPI meetings was that they were held on Wednesdays, and she was scheduled to work as the charge nurse and complete wound rounds. Interview on 1/31/24 at 3:45 p.m., with administrator identified he was unaware the infection preventionist was required to attend the QAPI meetings. He revealed he knew the director of nursing (DON) was required and thought the DON could relay the infection control information at…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-17 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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's current administration failed to ensure proper oversight nursing staff licensure. This deficient practice resulted in a licensed practical nurse (LPN) working scheduled shifts with administrations knowledge under an expired licensed. Findings include: Review of license practical nurse (LPN)-A employee file revealed an expired licensed as of [DATE]. Review of facility schedule revealed LPN-A was currently scheduled to be working and had been scheduled since [DATE]. During an interview on [DATE] at 5:05 p.m. LPN-A stated nursing license had expired on [DATE], and forgot to renew them. LPN-A confirmed she had worked from [DATE], until [DATE], as a licensed nurse without a current license. LPN-A also stated the director of nursing (DON) called her on [DATE], and informed her to renew her nursing license. LPN-A verified on [DATE], she had paid the $106 fee to renew nursing license, and on [DATE], the DON called and asked why her nursing license was still expired.…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-17 · tag F0839 — pattern
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    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 4 facility employed nursing staff (LPN)-A reviewed were currently licensed to practice nursing within the State. This had potential to affect all 42 residents living in the facility. Findings include: Review of license practical nurse (LPN)-A employee file revealed an expired licensed as of [DATE]. On [DATE], facility provided evidence of licensure for LPN-A during time of hire on [DATE]. LPN-A was listed as LPN on the Minnesota Board of Nursing (MNBON) with expiration date of license as [DATE]. On [DATE], facility provided evidence of licensure for LPN-A upon application process form dated [DATE]. LPN-A identified expiration date of Minnesota licensed practical nurse as [DATE]. On [DATE], facility provided a copy of a letter from MNBON dated [DATE], identified LPN-A nursing license expiration date as [DATE]. To practice nursing in Minnesota an individual must be licensed and currently registered. Your registration application has been…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer physician's order as written for 1 of 1 (R5) residents reviewed for steroid inhalation. Findings include: R5's quarterly Minimum data set (MDS) dated [DATE], identified R5 had intact cognition and no behaviors. R5 required limited assistance with transfers, locomotion, bed mobility, dressing, toilet use, and personal hygiene. R5's diagnoses included respiratory failure, asthma, chronic obstructive pulmonary disease (COPD), obesity, and congestive heart failure (CHF). R5's care plan dated 8/8/23, identified R5 had an altered respiratory status, difficulty breathing, decreased oxygen saturation levels. The staff were directed to observe, document, and report to nurse/medical practitioner any signs and symptoms of respiratory distress such as increased respirations or heart rate, oxygen levels 90% or below, restlessness, headaches, lethargy, confusion, use of accessory muscle (muscles, usually abdominal, used to provide assistance…

    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 · Dcited before2023-08-17 · 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 follow professional standards of practice during medication administration for 1 of 5 (R6) residents reviewed for medication administration. Findings include: R6's quarterly Minimum data set (MDS) dated [DATE], identified severely impaired cognition and no behaviors. R6 required extensive assistance for all activities of daily living and with transfers. R6's diagnosis was cerebral palsy (affects movement and muscle tone). R6's physician order dated 11/22/21, indicated Memantine HCL (hydrochloric acid) tablet five 10 milligrams (mg) by mouth in the evening for memory. During an observation on 8/16/23 at 4:22 p.m. license practical nurse (LPN)-A prepared R6's medications while she stood in the hallway in front of the medication cart. LPN-A punched the Memantine 10 mg tab out of the medication card and aimed for the medication cup but landed on the top of the medication cart. LPN-A picked up the pill with her bare hand and placed it into 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.

    Infection Control 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 ACCURA HEALTHCARE — 41 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 3 of 52.5+0.5 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 3 of 53.1-0.1 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 40 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Aberdeen Health And RehabAberdeen, SD 1 of 5Accura HealthCare of TekamahTekamah, NE 1 of 5Accura Healthcare of CarrollCarroll, IA 1 of 5Accura Healthcare of MarshalltownMarshalltown, IA 1 of 5Accura Healthcare of Newton East, LLCNewton, IA 1 of 5Accura Healthcare of O'NeillO' Neill, NE 1 of 5Accura Healthcare of Pleasantville, LLCPleasantville, IA 1 of 5Accura Healthcare of ShenandoahShenandoah, IA 1 of 5Green Lea Senior LivingMabel, MN 1 of 5Lake Andes Senior LivingLake Andes, SD 1 of 5Shell Rock Senior LivingShell Rock, IA 2 of 5Accura Healthcare of Cascade LLCCascade, IA 2 of 5Accura Healthcare of CrestonCreston, IA 2 of 5Accura Healthcare of FranklinFranklin, NE 2 of 5Accura Healthcare of Knoxville, LLCKnoxville, IA 2 of 5Accura Healthcare of Lake City, LLCLake City, IA 2 of 5Accura Healthcare of MuscatineMuscatine, IA 2 of 5Accura Healthcare of OnawaOnawa, IA 2 of 5Accura Healthcare of Spirit LakeSpirit Lake, IA 2 of 5Sterling Park Health Care CenterWaite Park, MN 2 of 5Woodlyn Heights Healthcare CenterInver Grove Heights, MN 3 of 5Accura Healthcare of Ames, LLCAmes, IA 3 of 5Accura Healthcare of Aurelia, LLCAurelia, IA 3 of 5Accura Healthcare of Cherokee, LLCCherokee, IA 3 of 5Accura Healthcare of FullertonFullerton, NE 3 of 5Accura Healthcare of Pomeroy, LLCPomeroy, IA 3 of 5Accura Healthcare of StantonStanton, IA 3 of 5Accura Healthcare of ToledoToledo, IA 3 of 5Meadow ManorGrand Meadow, MN 3 of 5Traditions Memory Care of NewtonNewton, IA 4 of 5Accura HealthCare of North PlatteNorth Platte, NE 4 of 5Accura Healthcare of Le MarsLe Mars, IA 4 of 5Accura Healthcare of MilfordMilford, IA 4 of 5Accura Healthcare of New HamptonNew Hampton, IA 4 of 5Accura Healthcare of Ogden, LLCOgden, IA 4 of 5Accura Healthcare of Sioux City, LLCSioux City, IA 4 of 5Faulkton Senior LivingFaulkton, SD 5 of 5Accura HealthCare of HartingtonHartington, NE 5 of 5Accura Healthcare of BancroftBancroft, IA 5 of 5Karlstad Healthcare Center INCKarlstad, MN

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
TEALWOOD ENTERPRISE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2012
GROFF, HOWARDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 09/03/2008
SHERIDAN, GAILIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 08/29/2008
HINRICHS, BRIANIndividualW-2 MANAGING EMPLOYEEsince 01/01/2023
YOUNG, JUSTINIndividualW-2 MANAGING EMPLOYEEsince 05/01/2024
LENEAVE, TEDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019
AMERICAN HEALTHCARE MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.3M
Net patient revenuemost recent cost report
+7.1%
Operating marginrevenue minus expenses
$232K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 45%Medicare 3%Other / private 52%

This home reported $232K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$277per resident / day
operating cost
$8,408per month
≈ monthly operating cost
$298per 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 245371. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, 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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